tag:blogger.com,1999:blog-35548671212257813362024-03-17T20:03:47.930-07:00Paediatric Emergency MedicineA curriculum based blog, linking existing resources together and matching them towards the College of Emergency Medicine CT3 Paediatric Emergency Medicine Syllabus. Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.comBlogger74125tag:blogger.com,1999:blog-3554867121225781336.post-10201115103578628862019-08-24T14:04:00.000-07:002019-08-24T14:04:51.099-07:00Headaches in ChildrenHeadaches need a good history in children - just like in adults! Unlike in adults, a head circumference is really important.<br />
If the headache is in a <5 year old refer to paeds.<br />
<blockquote class="twitter-tweet">
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Headache in children . <a href="https://twitter.com/hashtag/meded?src=hash&ref_src=twsrc%5Etfw">#meded</a> <a href="https://twitter.com/hashtag/foamed?src=hash&ref_src=twsrc%5Etfw">#foamed</a> <a href="https://twitter.com/hashtag/foamped?src=hash&ref_src=twsrc%5Etfw">#foamped</a> <a href="https://twitter.com/hashtag/pediatrics?src=hash&ref_src=twsrc%5Etfw">#pediatrics</a> <a href="https://t.co/7AOf3GPaCM">pic.twitter.com/7AOf3GPaCM</a></div>
— Manual Of Medicine (@ManualOMedicine) <a href="https://twitter.com/ManualOMedicine/status/1015304231010566145?ref_src=twsrc%5Etfw">July 6, 2018</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
<br />
<b>Brain Tumour</b><br />
Headache for more than 2 weeks with any other symptoms should get imaged - preferably with an MRI, but if not available a contrast CT.<br />
<br />
<b>Meningitis</b><br />
Similar to in adults.<br />
<br />
Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream.<br />
<br />
Meningococcal disease occurs as a result of a systemic bacterial infection by Neisseria meningitidis (meningococcus).<br />
<div style="background-color: white; box-sizing: border-box; color: #353535; font-family: Roboto; font-size: 16px; letter-spacing: 0.8px; line-height: 1.6; margin-bottom: 1.25rem; padding: 0px; text-rendering: optimizelegibility;">
<br /></div>
<b><br /></b>
<a href="https://adultemergencymedicine.blogspot.com/search/label/meningitis">https://adultemergencymedicine.blogspot.com/search/label/meningitis</a><br />
<a href="https://www.headsmart.org.uk/symptoms/signs-and-symptoms/children/persistent-recurrent-headache-children/">https://www.headsmart.org.uk/symptoms/signs-and-symptoms/children/persistent-recurrent-headache-children/</a><br />
<a href="https://assets.headsmart.org.uk/live/media/filer_public/c7/06/c706d496-44d4-461a-9319-0a5c3596d360/quickreferenceguide_spread_final.pdf">https://assets.headsmart.org.uk/live/media/filer_public/c7/06/c706d496-44d4-461a-9319-0a5c3596d360/quickreferenceguide_spread_final.pdf</a><br />
<a href="https://www.rcemlearning.co.uk/foamed/pem-headaches/">https://www.rcemlearning.co.uk/foamed/pem-headaches/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/meningococcal-disease-and-meningococcal-meningitis/">https://www.rcemlearning.co.uk/modules/meningococcal-disease-and-meningococcal-meningitis/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com18tag:blogger.com,1999:blog-3554867121225781336.post-4626484886490094742019-08-24T13:39:00.000-07:002019-08-24T13:39:29.613-07:00GI Bleeding in ChildrenAs far as I can tell, GI bleeding seems to be similar to in adults.<br />
<br />
There might be an <a href="https://paediatricem.blogspot.com/search/label/intussusception" target="_blank">intussusception</a>.<br />
There might be an <a href="http://adultemergencymedicine.blogspot.com/search/label/anal%20problems" target="_blank">anal fissure</a> (common).<br />
They might need an <a href="https://paediatricem.blogspot.com/search/label/IO" target="_blank">IO</a> for access.<br />
<br />
<u>Other References</u><br />
<a href="https://emedicine.medscape.com/article/1955984-overview">https://emedicine.medscape.com/article/1955984-overview</a><br />
<a href="https://www.rcemlearning.co.uk/modules/in-a-bit-of-a-jam/">https://www.rcemlearning.co.uk/modules/in-a-bit-of-a-jam/</a><br />
<a href="https://www.uptodate.com/contents/approach-to-upper-gastrointestinal-bleeding-in-children">https://www.uptodate.com/contents/approach-to-upper-gastrointestinal-bleeding-in-children</a><br />
<a href="https://www.rcemlearning.co.uk/modules/tired-purple-legs/">https://www.rcemlearning.co.uk/modules/tired-purple-legs/</a><br />
<br />Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com6tag:blogger.com,1999:blog-3554867121225781336.post-86597578802413461202019-08-24T13:03:00.001-07:002019-08-24T13:03:26.852-07:00Ear Problems<b>Otitis Media</b><br />
Any upper respiratory tract infection (often bacterial - strep) but may be viral can cause inflammation of the respiratory mucosa, with obstruction of the eustacian tube isthmus, with results in accumulation of middle ear secretions. This causes negative pressure which pulls viruses and bacteria into the middle ear.<br />
This increases the pressure causing otalgia and a bulging TM - the most obvious sign.<br />
75 - 80% resolve by 72 hours - most are better by 3 days.<br />
<br />
It is frequently overdiagnosed.<br />
<br />
Complications include hearing loss, recurrent otitis media, perforation, labyrinthitis, mastoiditis, facial palsy, meningitis, cerebral abscess and venous sinus thrombosis.<br />
<br />
Treatment is mostly with time. Watch and wait antibiotics may be useful.<br />
Amoxicillin is the first choice if antibiotics actually needed (bilateral infection, longer than 3 days, systemically poorly)<br />
<br />
<blockquote class="twitter-tweet">
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Decision Aid for Antibiotics in Otitis Media by <a href="https://twitter.com/PublicHealthON?ref_src=twsrc%5Etfw">@PublicHealthON</a>:<a href="https://t.co/wF9TQ7yM93">https://t.co/wF9TQ7yM93</a><a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/Meded?src=hash&ref_src=twsrc%5Etfw">#Meded</a> <a href="https://twitter.com/hashtag/DecisionAid?src=hash&ref_src=twsrc%5Etfw">#DecisionAid</a> images made searchable:<br /><br />"DecisionAid Antibiotics Otitis" -> <a href="https://t.co/z2S5rK15CU">https://t.co/z2S5rK15CU</a> <a href="https://t.co/2v3gBHi72I">pic.twitter.com/2v3gBHi72I</a></div>
— grepmed (@grepmeded) <a href="https://twitter.com/grepmeded/status/1095345539095425024?ref_src=twsrc%5Etfw">February 12, 2019</a></blockquote>
There may be an associated effusion (glue ear). Consider a hearing assessment especially if recurrent.<br />
<br />
<b>Otitis Externa</b><br />
This is often caused by bacteria and fungi, and less commonly viruses. The ear canal is swollen and sore with discharge- like a pimple. If there's mucous there, the discharge is probably from AOM. Treat with drops - antiseptic (acetic acid) and antibiotic (ciprofloxacin or aminoglycoside if no TM rupture).<br />
<br />
<b>Malignant Otitis Externa</b><br />
Very painful and often in the elderly. Caused by pseudomonas.<br />
<br />
<b>Foreign Bodies in the Ear</b><br />
Read this <a href="https://www.rcemlearning.co.uk/foamed/stuck-in-the-ear/" target="_blank">RCEMLearning</a> article.<br />
<br />
<b>Nose Trauma</b><br />
Nose trauma is common in children. There is a belief that nasal septal haematomas are more common - look for a cherry red haematoma in the nose.<br />
<br />
<a href="https://www.rcemlearning.co.uk/foamed/stuck-in-the-ear/">https://www.rcemlearning.co.uk/foamed/stuck-in-the-ear/</a><br />
<a href="https://journalfeed.org/article-a-day/2017/wait-and-see-antibiotics-for-otitis-media">https://journalfeed.org/article-a-day/2017/wait-and-see-antibiotics-for-otitis-media</a><br />
<a href="https://dontforgetthebubbles.com/otitis-media/">https://dontforgetthebubbles.com/otitis-media/</a><br />
<a href="https://www.nice.org.uk/guidance/ng91">https://www.nice.org.uk/guidance/ng91</a><br />
<a href="https://www.rcemlearning.co.uk/foamed/stuck-in-the-ear/">https://www.rcemlearning.co.uk/foamed/stuck-in-the-ear/</a><br />
<a href="https://www.gpnotebook.co.uk/simplepage.cfm?ID=-1241120761">https://www.gpnotebook.co.uk/simplepage.cfm?ID=-1241120761</a><br />
<a href="http://dontforgetthebubbles.com/otitis-externa/">http://dontforgetthebubbles.com/otitis-externa/</a><br />
<a href="https://emedicine.medscape.com/article/845525-overview">https://emedicine.medscape.com/article/845525-overview</a><br />
<a href="https://www.bmj.com/content/349/bmj.g6075">https://www.bmj.com/content/349/bmj.g6075</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com13tag:blogger.com,1999:blog-3554867121225781336.post-81587584360294186812019-08-23T06:01:00.000-07:002019-08-24T13:03:36.748-07:00Other Rashes<b>Chicken Pox</b><br />
Often blistering and crusting.<br />
Incubation 10-21days<br />
Infectivity when symptoms start<br />
<br />
<b>Measles </b><br />
Starts from the top and moves down. Often associated with conjunctival problems.<br />
Incubation 7 - 21days<br />
Infective - before symptoms to four days after appearance of rash<br />
Rash - maculopapular, spreads head downwards<br />
One of cough, conjunctivities or coryza<br />
- Get Koplik's spots, red throat<br />
- throat swab<br />
- notify if suspicious<br />
- off school until 5 days after rash<br />
- need immunoflobulin if under 12months, immunocompromised or pregnant.<br />
- MMR if unimmunised within 72hours of exposure<br />
MMR side effects are in the 2nd week after immunisation - fever and rash.<br />
<b><br /></b>
<b>Rubella or German Measles</b><br />
It's benign and self eliminating.<br />
- 2 week incubation<br />
- headache, fever, lymphadenopathy<br />
- infective 7 days efore, 7 days after onset of rash<br />
- rash face down to feet<br />
- fever, tender occipital and post auricular lymphadenopthy, arthralgia<br />
- Forschheimer spots - pin-point red macules and petechiae, seen on soft palate and uvula<br />
- Immuniglobulin G and M assays<br />
<br />
<b>Slapped Cheek / Parvovirus / Fifth Disease </b><br />
<b><br /></b>
<b>Scarlet Fever</b><br />
Pastias lines in the flexural folds with circumoral pallor, and pharyngitis. Desquamation of hands, feet and groin. Rash has a sandpaper-link quality.<br />
-aerosol/droplet<br />
- 2-5 days incubation<br />
- infective 5 days from antibiotics<br />
- sore throat, headache, fever, lymphadenopathy, malaise, abdopain. Sandpaper-like rash<br />
Strawberry tongue, pastias lines, circumoral pallor, pharyngitis, desquamation of hands feet and groin.<br />
- notify clinical suspicion<br />
- off school 5 days after antibiotics (HPA)<br />
- for grop A strep tonsillitis 24hours off after antibiotics.<br />
<br />
<b>Roseola</b>
<br />
The roseola rash often appears after the fever has settled.<br />
<blockquote class="twitter-tweet">
<div dir="ltr" lang="en">
<a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/FOAMpeds?src=hash&ref_src=twsrc%5Etfw">#FOAMpeds</a> <a href="https://twitter.com/hashtag/EmergencyMedicine?src=hash&ref_src=twsrc%5Etfw">#EmergencyMedicine</a> I just saw my 5th case of roseola this month, from the same daycare! As I was looking for a picture to show the parents, I came across this awesome pictorial to differentiate these 3 rashes: Rubella, Rubeola & Roseola. Save it in your phone! <a href="https://t.co/Jba4n9EtXq">pic.twitter.com/Jba4n9EtXq</a></div>
— Adan R Atriham (@GoodCPR) <a href="https://twitter.com/GoodCPR/status/1017237473771118594?ref_src=twsrc%5Etfw">July 12, 2018</a></blockquote>
<b>Herpes virus</b><br />
Fever + febrile illness<br />
5-15days incubation<br />
Respiratory illnesss, 3-5days fever, cervical lymphadenopathy<br />
Rash from behind ears - blanching macules and papules surrounded by halos<br />
Nagayama's spots- erythematous papules on the soft palate<br />
Diarrhoea<br />
Cough<br />
<br />
<br />
<b>Other References</b><br />
<a href="https://www.rcemlearning.co.uk/foamed/7-pem-rashes/">https://www.rcemlearning.co.uk/foamed/7-pem-rashes/</a><br />
<a href="https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/">https://www.rcemlearning.co.uk/reference/common-childhood-exanthems/</a><br />
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com7tag:blogger.com,1999:blog-3554867121225781336.post-47140011831379787962019-08-23T05:35:00.000-07:002019-08-23T05:35:44.377-07:00Rashes in Children<b>Eczema and Seborrhoeic Dermatitis</b><br />
Are essentially the same thing, and I think don't forgetthebubbles have it covered!<br />
<br />
<b>Bites and Infestations </b><br />
Lyme disease causes erythema migrans (pathognomic). If rash present treat - otherwise test. You can get a <span style="background-color: #f8f8f8; color: #728188; font-family: "roboto"; font-size: 16px; letter-spacing: 0.8px;">Jarisch-Herxheimer reaction - normally self limiting. Don't give routine prophylactic antibiotics. Remove a tip with direct forceful pressure. </span><br />
<span style="color: #728188; font-family: "roboto";"><span style="letter-spacing: 0.8px;"><br /></span></span>
<span style="color: #728188; font-family: "roboto";"><span style="letter-spacing: 0.8px;"><b>Dog Bites</b></span></span><br />
<span style="color: #728188; font-family: "roboto";"><span style="letter-spacing: 0.8px;">Probably OK for primary closure, and no routine prophylactic antibiotics. </span></span>
<b><br /></b><b>Human Bites</b><br />
Prophylactic antibiotics - always. Don't close if over 24hours old. Remember tetanus and BBV prophylaxis.<br />
<br />
<b>Scabies</b><br />
<blockquote class="twitter-tweet">
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All right <a href="https://twitter.com/hashtag/medtwitter?src=hash&ref_src=twsrc%5Etfw">#medtwitter</a>, ready to feel itchy? Get your Sarna ready and read on for a <a href="https://twitter.com/hashtag/tweetorial?src=hash&ref_src=twsrc%5Etfw">#tweetorial</a>/<a href="https://twitter.com/hashtag/medthread?src=hash&ref_src=twsrc%5Etfw">#medthread</a> on....<br /><br />SCABIES!!!<a href="https://twitter.com/hashtag/dermtwitter?src=hash&ref_src=twsrc%5Etfw">#dermtwitter</a> <a href="https://twitter.com/hashtag/dermatology?src=hash&ref_src=twsrc%5Etfw">#dermatology</a> <a href="https://twitter.com/hashtag/MedEd?src=hash&ref_src=twsrc%5Etfw">#MedEd</a> <a href="https://twitter.com/hashtag/FOAMEd?src=hash&ref_src=twsrc%5Etfw">#FOAMEd</a> pc: <a href="https://twitter.com/dermnetnz?ref_src=twsrc%5Etfw">@dermnetnz</a> <a href="https://twitter.com/hashtag/derm?src=hash&ref_src=twsrc%5Etfw">#derm</a> <a href="https://twitter.com/hashtag/itch?src=hash&ref_src=twsrc%5Etfw">#itch</a> <a href="https://twitter.com/hashtag/pruritus?src=hash&ref_src=twsrc%5Etfw">#pruritus</a> <br />1/</div>
— Steven Chen (@DrStevenTChen) <a href="https://twitter.com/DrStevenTChen/status/1156707598852349952?ref_src=twsrc%5Etfw">July 31, 2019</a></blockquote>
The classic burrows may be difficult to see in children. May look a bit pustular - but always VERY itchy! Treat with permethrin.<br />
<br />
<b>Head Lice or Nits</b><br />
Can you read this without itching?<br />
<br />
<b>References</b><br />
<a href="https://www.youtube.com/watch?v=QcpjbKCmqAw&feature=youtu.be">https://www.youtube.com/watch?v=QcpjbKCmqAw&feature=youtu.be</a><br />
<a href="https://www.rcemlearning.co.uk/reference/trek-tragedy-review-on-lyme-disease/">https://www.rcemlearning.co.uk/reference/trek-tragedy-review-on-lyme-disease/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/trek-tragedy-review-on-lyme-disease/exams/lyme-disease-post-test/">https://www.rcemlearning.co.uk/modules/trek-tragedy-review-on-lyme-disease/exams/lyme-disease-post-test/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/lemons-and-lymes/">https://www.rcemlearning.co.uk/modules/lemons-and-lymes/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/the-forest/">https://www.rcemlearning.co.uk/modules/the-forest/</a><br />
<a href="https://first10em.com/dog-bite/">https://first10em.com/dog-bite/</a><br />
<a href="https://rebelem.com/myths-management-dog-bites/">https://rebelem.com/myths-management-dog-bites/</a><br />
<a href="https://www.cochrane.org/CD001738/WOUNDS_antibiotics-for-reducing-the-rate-of-infection-after-bites-by-mammals-such-as-humans">https://www.cochrane.org/CD001738/WOUNDS_antibiotics-for-reducing-the-rate-of-infection-after-bites-by-mammals-such-as-humans</a><br />
<a href="https://cks.nice.org.uk/bites-human-and-animal">https://cks.nice.org.uk/bites-human-and-animal</a><br />
<a href="https://dontforgetthebubbles.com/mel-thompson-eradicating-scabies-at-dftb17/">https://dontforgetthebubbles.com/mel-thompson-eradicating-scabies-at-dftb17/</a><br />
<br />Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com6tag:blogger.com,1999:blog-3554867121225781336.post-56027704921920192019-08-22T14:54:00.002-07:002019-08-22T14:54:15.596-07:00TonsillitisMost of the tonsillitis syllabus has already been covered elsewhere.<br />
<br />
<br />
<a href="https://paediatricem.blogspot.com/2013/07/post-tonsillectomy-bleeding.html" target="_blank">Post Tonsillectomy Bleeding </a><br />
Tonsillitis - see <a href="https://adultemergencymedicine.blogspot.com/search/label/tonsillitis" target="_blank">adult notes </a><br />
Great resource from <a href="https://dontforgetthebubbles.com/ent-part-3-a-frog-in-your-throat/" target="_blank">DFTB</a><br />
<a href="https://paediatricem.blogspot.com/2013/07/epiglottitis.html" target="_blank">Epiglottitis</a><br />
FB in the throat <a href="https://paediatricem.blogspot.com/search/label/choking" target="_blank">(aka choking)</a><br />
<br />
<br />Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com7tag:blogger.com,1999:blog-3554867121225781336.post-88570865892955687592019-07-17T13:11:00.002-07:002019-07-17T13:11:57.002-07:00Purpura in Children<b>HSP</b><br />
Vasculitis with arthralgia, abdo pain, and or renal involvement. Purpura occurs in all patients. The rash is distinctive. Urinalysis is needed - manage with analgesia. Consider steroids.<br />
<br />
A first episode of HSP usually resolves within 4 weeks with the rash being the last symptom to go.<br />
Joint pain usually resolves spontaneously within 72 hours and abdo pain in 24- 48 hours.<br />
Uncomplicated abdominal pain usually resolves spontaneously within 24-48 hours<br />
<br />
<b>ITP</b><br />
Covered on <a href="https://dontforgetthebubbles.com/itp-idiopathic-thrombocytopenia-purpura/" target="_blank">DFTB</a>.<br />
<br />
<b>Petechial Rash </b><br />
The flow chart on <a href="http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/emergency-medicine/non-blanching-rash-management-in-children/" target="_blank">this website</a> is useful for highlighting when to investigate but this one is probably <a href="https://www.rch.org.au/uploadedFiles/Main/Content/clinicalguide/guideline_index/Fever%20and%20Petechiae%20Flowchart.pdf" target="_blank">the best</a>.<br />
<a href="https://www.nice.org.uk/guidance/cg102/resources/meningitis-bacterial-and-meningococcal-septicaemia-in-under-16s-recognition-diagnosis-and-management-pdf-35109325611205" target="_blank">NICE</a> say give ceftriaxone if:<br />
petechiae start to spread<br />
the rash becomes purpuric<br />
there are signs of bacterial meningitis<br />
there are signs of meningococcal septicaemia<br />
the child or young person appears ill to a healthcare professional<br />
A non specific viral illness is the most <a href="http://gppaedstips.blogspot.com/search/label/Non-blanching%20rash" target="_blank">likely cause</a> of the rash.<br />
<br />
<b>References</b><br />
<a href="https://www.rcemlearning.co.uk/foamed/7-pem-rashes/">https://www.rcemlearning.co.uk/foamed/7-pem-rashes/</a><br />
<a href="https://dontforgetthebubbles.com/henoch-schonlein-purpura-steroids-helpful-preventing-nephropathy/">https://dontforgetthebubbles.com/henoch-schonlein-purpura-steroids-helpful-preventing-nephropathy/</a><br />
<a href="https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/">https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/</a><br />
<a href="http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/emergency-medicine/non-blanching-rash-management-in-children/">http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/emergency-medicine/non-blanching-rash-management-in-children/</a><br />
<a href="https://dontforgetthebubbles.com/itp-idiopathic-thrombocytopenia-purpura/">https://dontforgetthebubbles.com/itp-idiopathic-thrombocytopenia-purpura/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com4tag:blogger.com,1999:blog-3554867121225781336.post-9698020200642865412019-07-14T09:37:00.002-07:002019-07-14T09:37:33.581-07:00BRUEA BRUE or an ALTE needs thorough history taking and examination.<br />
<br />
It is defined as:<br />
<br />
“an episode that is frightening to the observer and that is<br />
characterized by some combination of apnea (central or obstructive), color<br />
change (usually cyanotic or pallid, but occasionally erythematous or plethoric)<br />
marked change in muscle tone (usually marked limpness), choking"<br />
<br />
ie Apnoea, Looks Different, Tone different, Exhibits unconsciousness<br />
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ALTE? That's so 2015. It's now BRUE (brief,resolved,unexplained)<a href="https://t.co/qBS9GRcXW7">https://t.co/qBS9GRcXW7</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> via <a href="https://twitter.com/AmerAcadPeds?ref_src=twsrc%5Etfw">@AmerAcadPeds</a> <a href="https://t.co/VlHVpjOxSY">pic.twitter.com/VlHVpjOxSY</a></div>
— Lauren Westafer (@LWestafer) <a href="https://twitter.com/LWestafer/status/724705413875286016?ref_src=twsrc%5Etfw">April 25, 2016</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
<br />
If this occurs whilst the child is sleeping, it may be apnoea of infancy. The child may also have insomina, hypersomnia etc. History will be key!<br />
<br />
<br />
Take a careful history. And if there are no high risk features, the child can probably go home.
<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
Learning about high risk features of BRUE and recommended testing during a Sunday AM shift <a href="https://twitter.com/RushEmergency?ref_src=twsrc%5Etfw">@RushEmergency</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://t.co/FhxaMTc7fQ">pic.twitter.com/FhxaMTc7fQ</a></div>
— Michael Gottlieb (@MGottliebMD) <a href="https://twitter.com/MGottliebMD/status/1061629264406216705?ref_src=twsrc%5Etfw">November 11, 2018</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>References<br />
<a href="https://pedemmorsels.com/brue/">https://pedemmorsels.com/brue/</a><br />
<a href="http://dontforgetthebubbles.com/brue-is-the-new-black/%C2%A0" target="_blank">http://dontforgetthebubbles.com/brue-is-the-new-black/ </a><br />
<a href="http://www.stemlynsblog.org/alte-brue/">http://www.stemlynsblog.org/alte-brue/</a><br />
<a href="http://foamcast.org/2016/05/04/episode-49-the-aap-brue-guidelines/">http://foamcast.org/2016/05/04/episode-49-the-aap-brue-guidelines/</a><br />
<a href="https://www.ncbi.nlm.nih.gov/pubmed/15499062">https://www.ncbi.nlm.nih.gov/pubmed/15499062</a><br />
<a href="https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/central-sleep-apnoea-syndrome-csa">https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/central-sleep-apnoea-syndrome-csa</a><br />
<a href="http://sleepeducation.org/sleep-disorders-by-category/sleep-breathing-disorders/infant-sleep-apnea/overview-facts">http://sleepeducation.org/sleep-disorders-by-category/sleep-breathing-disorders/infant-sleep-apnea/overview-facts</a><br />
<a href="https://www.rcemlearning.co.uk/foamed/pem-and-ex-prems/">https://www.rcemlearning.co.uk/foamed/pem-and-ex-prems/</a><br />
<a href="https://www.rcemlearning.co.uk/reference/myocarditis/">https://www.rcemlearning.co.uk/reference/myocarditis/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/causes-and-management-of-myocarditis/">https://www.rcemlearning.co.uk/modules/causes-and-management-of-myocarditis/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com0tag:blogger.com,1999:blog-3554867121225781336.post-89385815586969666472019-07-14T09:12:00.001-07:002019-07-14T09:12:34.530-07:00Self Harm in ChildrenFrom a medical point of view, it is worth remembering that especially in toddlers who have a low mass, one pill can kill. Especially:<br />
- Cardiac drugs<br />
- Antidiabetics<br />
- Antidepressents<br />
- Iron, vicks, pepto - bismul (contains salicylates)<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
One pill killers: Do you know which common drugs are potentially fatal for a small child with ONE pill?<a href="https://t.co/OehAgPqmb7">https://t.co/OehAgPqmb7</a><a href="https://twitter.com/hashtag/MedEd?src=hash&ref_src=twsrc%5Etfw">#MedEd</a> <a href="https://twitter.com/hashtag/toxicology?src=hash&ref_src=twsrc%5Etfw">#toxicology</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://t.co/cPdiHUhnXj">pic.twitter.com/cPdiHUhnXj</a></div>
— Paediatric FOAMed (@PaediatricFOAM) <a href="https://twitter.com/PaediatricFOAM/status/1032197760538304518?ref_src=twsrc%5Etfw">August 22, 2018</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
<br />
From a mental health point of view - remember to complete all safeguarding paperwork, and encourage talking and communication.<br />
<br />
<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
Children’s mental health is a hugely increasing problem of our times. We see it in ED at its worst but remember all parents & carers have to consider their own & their kid’s mental health. Put this poster up in your ED - if it helps 1 family you’ve won <a href="https://twitter.com/hashtag/MentalHealthAwarnessWeek?src=hash&ref_src=twsrc%5Etfw">#MentalHealthAwarnessWeek</a> <a href="https://t.co/boe6ufklSY">pic.twitter.com/boe6ufklSY</a></div>
— ED Doc (@4hrEmergencyDoc) <a href="https://twitter.com/4hrEmergencyDoc/status/1128777697017180160?ref_src=twsrc%5Etfw">May 15, 2019</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>Your thorough HEADSSS assessment will help make sure all important points are covered.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPizdxY1YZ2dKLwpHzvsxreOD1cwcgRZbSX89I7ZuGPyZ4-n5qN0UCnMAxzfYMRuydiP2oXdM7PqGecOiGwcACMzKA1MYv2XfEFSbwkrs6TYrxmi5qjTnwq09gk_-iRp7YUQLxid90Z9Y/s1600/HEADS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="804" data-original-width="1186" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPizdxY1YZ2dKLwpHzvsxreOD1cwcgRZbSX89I7ZuGPyZ4-n5qN0UCnMAxzfYMRuydiP2oXdM7PqGecOiGwcACMzKA1MYv2XfEFSbwkrs6TYrxmi5qjTnwq09gk_-iRp7YUQLxid90Z9Y/s320/HEADS.jpg" width="320" /></a></div>
References<br />
<a href="https://pemgeek.com/2016/10/27/one-pill-killers/">https://pemgeek.com/2016/10/27/one-pill-killers/</a><br />
<a href="https://www.nice.org.uk/guidance/cg133/resources/selfharm-in-over-8s-longterm-management-pdf-35109508689349">https://www.nice.org.uk/guidance/cg133/resources/selfharm-in-over-8s-longterm-management-pdf-35109508689349</a><br />
<a href="https://www.nice.org.uk/guidance/cg16/resources/selfharm-in-over-8s-shortterm-management-and-prevention-of-recurrence-pdf-975268985029">https://www.nice.org.uk/guidance/cg16/resources/selfharm-in-over-8s-shortterm-management-and-prevention-of-recurrence-pdf-975268985029</a><br />
<a href="https://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh">https://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh</a><br />
<a href="https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap2/">https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap2/</a><br />
<a href="https://www.rcemlearning.co.uk/modules/paediatric-toxicology-considerations/">https://www.rcemlearning.co.uk/modules/paediatric-toxicology-considerations/</a><br />
<a href="https://youngminds.org.uk/find-help/for-parents/parents-guide-to-support-a-z/parents-guide-to-support-self-harm/">https://youngminds.org.uk/find-help/for-parents/parents-guide-to-support-a-z/parents-guide-to-support-self-harm/</a><br />
<a href="https://www.nspcc.org.uk/preventing-abuse/keeping-children-safe/self-harm/">https://www.nspcc.org.uk/preventing-abuse/keeping-children-safe/self-harm/</a><br />
<a href="https://www.rcemlearning.co.uk/foamed/the-3cs-of-paediatrics/">https://www.rcemlearning.co.uk/foamed/the-3cs-of-paediatrics/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com1tag:blogger.com,1999:blog-3554867121225781336.post-34071056577077267822019-07-14T07:30:00.000-07:002019-07-14T07:30:02.505-07:00Kawasaki Disease Medium sized artery vasculitis in children under five years old.<br />
Unknown aetiology but possibly infection.<br />
Higher risk in Asians, especially Japenese and Koreans.<br />
<br />
Signs
<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/hashtag/fcem?src=hash&ref_src=twsrc%5Etfw">#fcem</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="https://twitter.com/hashtag/paediatrics?src=hash&ref_src=twsrc%5Etfw">#paediatrics</a> Features of Kawasaki disease. <a href="http://t.co/cZkF241IaA">pic.twitter.com/cZkF241IaA</a></div>
— #hellomynameisDrKirsty (@KirstyChallen) <a href="https://twitter.com/KirstyChallen/status/590433251463979008?ref_src=twsrc%5Etfw">April 21, 2015</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
or
<br />
<blockquote class="twitter-tweet" data-lang="en">
<div dir="ltr" lang="en">
Symptoms of Kawasaki Disease can be remembered by the mnemonic "CREAM" - <a href="http://t.co/4EKqYRMqbP">http://t.co/4EKqYRMqbP</a> <a href="https://twitter.com/hashtag/USMLE?src=hash&ref_src=twsrc%5Etfw">#USMLE</a> <a href="https://twitter.com/hashtag/FOAMed?src=hash&ref_src=twsrc%5Etfw">#FOAMed</a> <a href="http://t.co/zBmzrAXc12">pic.twitter.com/zBmzrAXc12</a></div>
— knowmedge (@knowmedge) <a href="https://twitter.com/knowmedge/status/427781754678566912?ref_src=twsrc%5Etfw">January 27, 2014</a></blockquote>
<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>
In the absense of inflammation (high WCC or CRP) Kawasaki is unlikely.<br />
Don't wait for fever >5 days to diagnose it though - it might be incomplete.<br />
<br />
<a href="https://www.rcemlearning.co.uk/foamed/a-child-with-a-fever/">https://www.rcemlearning.co.uk/foamed/a-child-with-a-fever/</a><br />
<a href="https://adc.bmj.com/content/99/1/74">https://adc.bmj.com/content/99/1/74</a><br />
<a href="https://www.paediatricfoam.com/2017/06/kawasaki-disease-pearls-and-pitfalls/?subscribe=success#blog_subscription-4">https://www.paediatricfoam.com/2017/06/kawasaki-disease-pearls-and-pitfalls/?subscribe=success#blog_subscription-4</a><br />
<a href="http://dontforgetthebubbles.com/kawasaki-disease-beware-the-incomplete/">http://dontforgetthebubbles.com/kawasaki-disease-beware-the-incomplete/</a><br />
<a href="http://rolobotrambles.com/notjustafever/">http://rolobotrambles.com/notjustafever/</a><br />
<a href="https://calgaryguide.ucalgary.ca/wp-content/uploads/image.php?img=2017/05/Kawasaki-Disease.jpg">https://calgaryguide.ucalgary.ca/wp-content/uploads/image.php?img=2017/05/Kawasaki-Disease.jpg</a><br />
<br />Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com1tag:blogger.com,1999:blog-3554867121225781336.post-6375774518889815612017-07-06T09:06:00.004-07:002017-07-06T09:06:51.235-07:00Nasal Foreign Body Nasal foreign bodies are surprisingly common. The technique is not too dissimilar to that of removing auricular foreign bodies. In theory, they might be hidden behind a turbinate and tricky to see - and therefore tricky to remove.<br />
<br />
1. Mother's Kiss<br />
This works in 60% of cases. Occlude patent nostril. Get Mum to blow into the mouth. You can do this with a BVM if needed - but be careful the pressure isn't too high.<br />
<br />
2. Suction<br />
Like with FBs in the ear, gentle suction, can help. I guess glue could too - although I haven't seen any case reports of this.<br />
<br />
3. Curved Needles<br />
If you can't find one, as we can never find them in the ED, bend a green needle, and that should help!<br />
<br />
4. Foley Catheter<br />
Inflate baloon with 0.5 - 3ml water or air. Insert it behind the foreign body, and then pull. I've never tried this, but it seems to be really frequently used outside the UK!<br />
<b><u><br /></u></b>
<b><u>References</u></b><br />
<a href="http://journals.lww.com/em-news/blog/M2E/Pages/post.aspx?PostID=17">http://journals.lww.com/em-news/blog/M2E/Pages/post.aspx?PostID=17</a><br />
<a href="http://www.emdocs.net/ear-nose-throat-foreign-bodies/%C2%A0" target="_blank">http://www.emdocs.net/ear-nose-throat-foreign-bodies/ </a><br />
<a href="https://wikem.org/wiki/Nasal_foreign_body%C2%A0" target="_blank">https://wikem.org/wiki/Nasal_foreign_body </a><br />
<a href="http://pmj.bmj.com/content/76/898/484">http://pmj.bmj.com/content/76/898/484</a><br />
<a href="http://epmonthly.com/article/how-to-remove-a-nasal-foreign-body-with-a-balloon-catheter/">http://epmonthly.com/article/how-to-remove-a-nasal-foreign-body-with-a-balloon-catheter/</a><br />
<a href="https://lifeinthefastlane.com/nasal-foreign-bodies/">https://lifeinthefastlane.com/nasal-foreign-bodies/</a><br />
<a href="http://www.racgp.org.au/download/Documents/AFP/2013/May/201305handi.pdf%C2%A0" target="_blank">http://www.racgp.org.au/download/Documents/AFP/2013/May/201305handi.pdf </a><br />
<a href="http://emedicine.medscape.com/article/763767-overview?pa=kFsFTvrB8j%2FPtwK%2BOEAs61ub09VNBtvaAN6mPVwMp%2FDFndF9mwj4ym0rESwqOfDUa5AxknqcRm1Zi18mAza%2B0XnZ5j5IICuJuaa3Z%2BY2XGY%3D#a4">http://emedicine.medscape.com/article/763767-overview?pa=kFsFTvrB8j%2FPtwK%2BOEAs61ub09VNBtvaAN6mPVwMp%2FDFndF9mwj4ym0rESwqOfDUa5AxknqcRm1Zi18mAza%2B0XnZ5j5IICuJuaa3Z%2BY2XGY%3D#a4</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com3tag:blogger.com,1999:blog-3554867121225781336.post-25078939534803693552017-07-06T06:45:00.000-07:002017-07-06T06:45:44.272-07:00Ear Foreign Bodies Extracting foreign bodies from the ear can be very painful, and it is easy to impact them where the auditory canal narrows. 75% of patients with ear foreign bodies are younger than eight.<br />
<br />
To start with:<br />
- Check if there's a tympanic membrane perforation. If you can't see whether there is or not, that makes things trickier.<br />
- Position the patient comfortably and securely<br />
- Consider anesthetising the ear - some lignocaine dripped in may well help. Blocks don't tend to be too helpful - if this fails, think about general anaesthesia or sedation.<br />
- Check whether you should be removing this. ENT should help with button batteries, sharp objects, tightly wedged FBs, and FBs you can't remove after multiple attempts.<br />
- When successfully removed, double check you've removed it. Consider prophylactic antibiotic drops.<br />
<br />
<i>Potential Methods: </i><br />
1. Forceps Removal<br />
If the FB is "graspable" this can be useful.<br />
<br />
2. Irrigation<br />
This is especially useful if there is a live insect in the ear. The insect must be killed with alcohol, 2% lignocaine or mineral oil - but hopefully you can check there is no tympanic membrane perforation first. Once the insect is dead, suction might remove it more effectively than grasping or forceps as this can cause shedding. Until the insect is dead, remember it might try to fly towards the otoscope light - this can be uncomfortable for the patient!<br />
Don't irrigate button batteries in the ear.<br />
Don't irrigate organic matter that might swell, and get wedged.<br />
Don't forget to use warm water - as the patient won't thank you if the water is cold, as it can cause vertigo and vomiting. If you're having trouble directing the irrigation, think about getting a cannula (needle out) connected to a syringe (that you can gently flush).<br />
<br />
3. Modified Suction<br />
We don't have microsuction like ENT do, but cutting a 12Fr suction catheter short, and then applying gentle suction, may help. Equally, cutting the soft tubing from a butterfly needle, and using that for suction may help.<br />
<br />
4. Glue<br />
A bit of wound glue on the end of a syringe or Q tip can adhere to the foreign body and pull it out. You're going to have to be pretty convinced you're going to get the Foreign Body out, and not just stick the FB further to the ear canal! If you do this, it might be worth putting an ear speculum on the foreign body, then guiding the glue in that way - it protects the rest of the ear canal. You really do need a compliant patient.<br />
<br />
5. Magnets<br />
A small magnet may help remove a magnetic foreign body.<br />
<u><br /></u>
<u>References</u><br />
<a href="https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/">https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/</a><br />
<a href="http://www.bcmj.org/article/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer">http://www.bcmj.org/article/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer</a><br />
<a href="https://www.aliem.com/2011/06/trick-of-trade-mini-suction-device/">https://www.aliem.com/2011/06/trick-of-trade-mini-suction-device/</a><br />
<a href="https://www.aliem.com/2015/08/trick-of-the-trade-ear-foreign-body-removal-with-modified-suction-setup/">https://www.aliem.com/2015/08/trick-of-the-trade-ear-foreign-body-removal-with-modified-suction-setup/</a><br />
<a href="http://www.emdocs.net/ear-nose-throat-foreign-bodies/%C2%A0" target="_blank">http://www.emdocs.net/ear-nose-throat-foreign-bodies/ </a><br />
<a href="http://web.a.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=0002838X&AN=27084070&h=KhnZ0t%2fe0WQaT0VcI35%2bowCQHYayQbKGPoHg4Ww9ICGwhN9D%2bov6rYNcHaJLgf4Zu0iekyIC5PNnhn%2fqrqin3A%3d%3d&crl=f&resultNs=AdminWebAuth&resultLocal=ErrCrlNotAuth&crlhashurl=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler%26jrnl%3d0002838X%26AN%3d27084070" target="_blank">AFP</a><br />
<a href="https://www.aliem.com/2014/10/trick-of-trade-insect-removal-from-the-ear/%C2%A0" target="_blank">https://www.aliem.com/2014/10/trick-of-trade-insect-removal-from-the-ear/ </a><br />
<a href="https://www.aliem.com/2016/08/trick-of-trade-ear-irrigation/%C2%A0" target="_blank">https://www.aliem.com/2016/08/trick-of-trade-ear-irrigation/ </a><br />
<a href="https://www.aliem.com/2012/05/trick-of-trade-ear-foreign-body-2/%C2%A0" target="_blank">https://www.aliem.com/2012/05/trick-of-trade-ear-foreign-body-2/ </a><br />
<a href="http://pedemmorsels.com/ear-foreign-body/">http://pedemmorsels.com/ear-foreign-body/</a><br />
<a href="http://emj.bmj.com/content/17/2/91%C2%A0" target="_blank">http://emj.bmj.com/content/17/2/91 </a><br />
<a href="http://www.pemed.org/blog/2014/4/9/anyone-seen-my-corn-pediatric-foreign-bodies.html">http://www.pemed.org/blog/2014/4/9/anyone-seen-my-corn-pediatric-foreign-bodies.html</a><br />
<a href="http://emj.bmj.com/content/22/4/266">http://emj.bmj.com/content/22/4/266</a><br />
<a href="https://wikem.org/wiki/Ear_foreign_body%C2%A0" target="_blank">https://wikem.org/wiki/Ear_foreign_body </a><br />
<a href="http://emblog.mayo.edu/2017/04/04/stick-glue-and-cone-for-ear-foreign-bodies/">http://emblog.mayo.edu/2017/04/04/stick-glue-and-cone-for-ear-foreign-bodies/</a><br />
<a href="https://entsho.com/removing-foreign-bodies/">https://entsho.com/removing-foreign-bodies/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com2tag:blogger.com,1999:blog-3554867121225781336.post-35518647819775441782016-10-27T07:30:00.002-07:002016-10-27T07:30:49.661-07:00Collapsed Neonates<b>Resuscitate</b><br />
As per appropriate<br />
Adrenaline 10mcg/kg<br />
<div>
<br /></div>
<i>Prostin - </i><br />
- 5 ng/kg/min if clinically well<br />
- 20 ng/kg/min if unstable or absent femoral pulses<br />
- 50-100 ng/kg/min if no response<br />
Apnoea common: 1st hr of Rx, dose<br />
Hypotension may occur with high dose<br />
<br />
<b>Prostin</b><br />
- 5 ng/kg/min if clinically well<br />
- 20 ng/kg/min if unstable or absent femoral pulses<br />
- 50-100 ng/kg/min if no response<br />
Apnoea common: 1st hr of Rx, dose<br />
<br />
Hypotension may occur with high dose<br />
<br />
<b>Think about Causes</b><br />
<i>Infection</i><br />
Group B strep, E Coli - PROM, maternal GBS, fever in labour<br />
Herpes Simplex - GCS, coagulopathy, ALT, family cold sores<br />
MRSA - Unresponsive 1st line antibiotics,+ contact<br />
<br />
<i>Cardiac</i><br />
Coarctation aorta - Systolic arm/leg gradient > 20 mmHg<br />
Hypoplastic Left heart - Poor pulses –may be pink= pulm. overcirculation<br />
Transposition (TGA) - Preductal sats < post ductal sats<br />
TAPVD (obstructed) - Shocked & cyanosed/CXR plethoric<br />
SVT - HR>220 despite fluid, f ixed HR, narrow QRS<br />
Myocarditis - Cardiac failure, tachycardia, small QRS<br />
<div>
<br /></div>
<i>Injury </i><br />
Intracranial bleed - Focal neuro signs, fontanel le , retinal bleeds<br />
Intrabdominal bleed - Unexplained anaemia, abdominal bruising<br />
<div>
<br /></div>
<i>Cardiac</i><br />
<i><br /></i><i>Metabolic</i><br />
Vomiting, reduced GCS, hypoglycaemia<br />
Stop the feeds. Give fluid and dextrose as highly likely to be fluid depleted<br />
<br />
<b>References</b><br />
<a href="http://paediatricem.blogspot.co.uk/search/label/NLS">http://paediatricem.blogspot.co.uk/search/label/NLS</a><br />
<a href="http://www.rcemlearning.co.uk/references/congenital-heart-disease/%C2%A0" target="_blank">http://www.rcemlearning.co.uk/references/congenital-heart-disease/ </a><br />
<a href="http://www.rcemlearning.co.uk/modules/the-shocked-neonate/" target="_blank">http://www.rcemlearning.co.uk/modules/the-shocked-neonate/ </a><br />
<a href="http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/" target="_blank">http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/ </a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com25tag:blogger.com,1999:blog-3554867121225781336.post-69178989315193822382016-02-07T08:32:00.000-08:002016-02-07T08:32:59.625-08:00Long Bone Fractures - in ChildrenFemoral fractures are uncommon, as considerable force is often required. There is often a history of a fall with the leg twisted awkwardly. In children fractures are more common at the physis, and we need to know about the "SALTER" classification. There is a bimodal distribution of femoral fractures - they are common in 2 - 4 year olds, and adolescents. We should always consider child abuse and non accidental injury, especially if the fracture presents in a patient before walking age.<br />
<br />
<b>Radiology of Note</b><br />
The distal femoral epiphyses are normally present from birth to 18 -20 years<br />
The patella ossifies between 3 - 6 years<br />
<br />
<b>Management</b><br />
Support the leg with the hip and knee slightly flexed<br />
Analgesia (intra-nasal very likely to be helpful)<br />
Splintage<br />
X-ray<br />
Traction<br />
Orthopaedic referral<br />
<br />
<b>Splinting</b><br />
Most sources agree that splinting should be carried out as soon as possible, although practically this can be difficult.<br />
< 3months: Pavlick harness<br />
>3 months/ 16kg: Gallows traction<br />
> 16kg: Thomas splint (skin traction)<br />
<br />
I have written a <a href="https://drive.google.com/file/d/0B9kNaFOXCBo7ZHlTR3ZqdjJaLTA/view?usp=sharing" target="_blank">presentation</a> that says all this with pretty pictures.<br />
<br />
<b>References</b><br />
<a href="http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/%C2%A0" target="_blank">http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/ </a><br />
<a href="http://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures--pediatric">http://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures--pediatric</a><br />
<a href="http://www.tamingthesru.com/blog/acmc/traction-splints-applying-the-ktd-traction-splint%C2%A0" target="_blank">http://www.tamingthesru.com/blog/acmc/traction-splints-applying-the-ktd-traction-splint </a><br />
<a href="http://www.ncbi.nlm.nih.gov/pubmed/23922601%C2%A0" target="_blank">http://www.ncbi.nlm.nih.gov/pubmed/23922601 </a><br />
<a href="http://www.youtube.com/watch?v=DNyyYdtOX5Q" target="_blank">http://www.youtube.com/watch?v=DNyyYdtOX5Q </a><br />
<a href="http://www.sciencedirect.com/science/article/pii/S002013831500577X" target="_blank">http://www.sciencedirect.com/science/article/pii/S002013831500577X </a><br />
<a href="http://www.bestbets.org/bets/bet.php?id=1533" target="_blank">http://www.bestbets.org/bets/bet.php?id=1533 </a><br />
<a href="http://www.sort.nhs.uk/Media/Guidelines/Wessexchildrensmajortraumaguidelines.pdf" target="_blank">http://www.sort.nhs.uk/Media/Guidelines/Wessexchildrensmajortraumaguidelines.pdf </a><br />
<a href="http://www2.rcn.org.uk/__data/assets/pdf_file/0004/608971/RCNguidance_traction_WEB_2.pdf">http://www2.rcn.org.uk/__data/assets/pdf_file/0004/608971/RCNguidance_traction_WEB_2.pdf</a><br />
<a href="http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X" target="_blank">Emergency Care of Minor Trauma in Children. Ffion Davies et al. </a><br />
<a href="http://www.amazon.co.uk/ABC-Emergency-Radiology-David-Nicholson/dp/0727908324/ref=sr_1_2?s=books&ie=UTF8&qid=1454862363&sr=1-2&keywords=abc+of+emergency+radiology" target="_blank">ABC of Emergency Radiology</a><br />
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Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com0tag:blogger.com,1999:blog-3554867121225781336.post-90426097191512602552015-06-12T15:10:00.000-07:002019-07-20T14:39:53.585-07:00Auricular HaematomaDrainage of an auricular haematoma is one of the "new" practical procedures that has popped up on our e-portfolio. This is difficult to get signed off because there are minimal resources on it, and it's not a skill I've ever seen performed in the ED. I'm not sure if it's because I'm missing them, and not looking hard enough for them, or if it quite simply isn't a procedure we do in the ED. I've seen ear lacs and swollen ears - I must be missing something.<br />
<br />
<b>What is An Auricular Haematoma?</b><br />
An auricular haematoma is a collection of blood that forms between the cartilage and the perichondrium of the ear. It is most often caused by blunt trauma to the ear.<br />
<br />
<b>Initial Treatment</b><br />
Needle aspiration is often recommended. This failed in 75% of cases - maybe because the needle itself introduces haematoma.<br />
<br />
<b>Incision and Drainage</b><br />
Incise along an anatomic crease to avoid a scar. Use forceps to encourage all of the haematoma out. Put a drain in, and then a dressing for compression. Prophylactic antibiotics have no evidence.<br />
<br />
<a href="https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=228">https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=228</a><br />
<a href="http://lifeinthefastlane.com/common-ear-complaints-in-the-ed/">http://lifeinthefastlane.com/common-ear-complaints-in-the-ed/</a><br />
<a href="http://journals.lww.com/em-news/Fulltext/2006/04000/Diagnosis__Traumatic_Auricular_Hematoma.20.aspx">http://journals.lww.com/em-news/Fulltext/2006/04000/Diagnosis__Traumatic_Auricular_Hematoma.20.aspx</a><br />
<a href="http://www.epmonthly.com/departments/clinical-skills/visual-dx/how-to-treat-an-auricular-hematoma-in-the-emergency-department-photo-guide/">http://www.epmonthly.com/departments/clinical-skills/visual-dx/how-to-treat-an-auricular-hematoma-in-the-emergency-department-photo-guide/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com1tag:blogger.com,1999:blog-3554867121225781336.post-37275334513928118822015-06-12T13:17:00.002-07:002016-02-07T16:32:00.159-08:00Sickle CellSickle cell disease is really common where I work and I've seen lots of different presentations. Our management seems a little different, and more rational, than some of the guidelines I've found on the internet - it was an interesting literature search.<br />
<b><br /></b>
<b>Patho-physiology</b><br />
Once again, the Calgary guide explains this better than I ever could.<br />
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><span style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><a href="http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease.jpg" target="_blank"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7-OBcqLYuzyjkdzPaV8ZMw_lQamJ7ol8lh82PIfWxvSlc8xxRQqrH7ZqTOj7oVCGB7KyV2fPY685J8mmCe34VTJI8eEG9HRAqeieCvNlmt6NiOMb0ZGzdpBiNVKwUlRmM8I2v5WYBsng/s200/Sickle+cell+disease.jpg" width="200" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease.jpg" target="_blank">The Calgary Guide</a></td></tr>
</tbody></table>
Glu --> Val substitution of the sixth amino acid of the beta-globin chain<br />
Get HbS instead<br />
<br />
Heterozygous: 45% HbS, 52% HbA, 2% HbA2, 1% HbF<br />
Sickle trait - increased renal cancer but no "disease"<br />
Homozygous: 90% HbS, 8% HbF, 2%HbA2<br />
<br />
HbS is less soluble so might precipitate. This means they become sickle shaped. Can be precipitated by dehydration, hypoxemia or acidosis.<br />
<br />
<b>Clinical Signs</b><br />
Have you looked at the Calgary guide? It is a very under-rated resource.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjt5h-iXK5HIR2eYB07-_qXJdW79Rs4WA1JY6OQHTq72D561auINjs-aOrJ_0YuvPXrgsUp_u7HFAL7L3Ccf2EZTYeFVDJ4VWeoZnm3jpW6PbPLo9hOfBURbMx8cFqkTm6UTKajekCcL4E/s1600/Sickle+cell+disease+signs.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjt5h-iXK5HIR2eYB07-_qXJdW79Rs4WA1JY6OQHTq72D561auINjs-aOrJ_0YuvPXrgsUp_u7HFAL7L3Ccf2EZTYeFVDJ4VWeoZnm3jpW6PbPLo9hOfBURbMx8cFqkTm6UTKajekCcL4E/s200/Sickle+cell+disease+signs.jpg" width="200" /></a> </div>
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<i>Crisis</i></div>
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A painful crisis is the most common presentation to the ED for sickle cell. Vaso-occlusion causes many problems - priapism, splenic sequestration, dactylitis, splenic infarction, stroke, renal failure, necrosis of the femoral head, blockage of the lung vessels and painful crises. </div>
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Painful crises are more common in the limbs and backs. The pain is normally throbbing, sharp or gnawing. </div>
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- Splenic infarction means RBC not removed by the spleen leading to Howell-Jolly bodies on blood smear. </div>
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- Aplastic crisis causes anaemia, pallor, tachycardia and a low reticulocyte count. </div>
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- Extravascular haemolysis causes a normocytic anaemia. As the red blood cells breakdown, there can be jaundice, and increase in gallstone formation. There can be increased marrow production to compensate for haemolysis. </div>
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<i>Nocturnal Enuresis</i></div>
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<i>Pulmonary Hypertension</i></div>
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Develops in 15-35% of children with SCD.</div>
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<i>Acute Chest Syndrome</i></div>
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This is most common in children, especially at around age three. It presents with fever, chest pain, difficulty in breathing and shadows on CXR. </div>
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Need to treat the pneumonia / infection and have urgent transfusion. Be careful as overhydration may lead to oedema and pulmonary vascular congestion. </div>
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<i>Splenic Sequestration</i></div>
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This is a major cause of mortality, especially in those less than five years old. Major causes a rapid drop of Hb, pallor, LUQ pain, splenomegaly. Minor is more gradual onset. </div>
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<i>Neurological Disease</i></div>
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Strokes are common - up to 25% of patients. They need urgent imaging, and urgent exchange transfusion.</div>
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<i>Dactylitis</i></div>
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This is often the presenting feature in children, and normally resolves in a few days. </div>
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<i>Hyphema</i></div>
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If there is any eye trauma, look carefully for a hyphema - it may not be obvious. Refer anyone who has protrusion of the eye, changes in visual acuity or loss of vision. </div>
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Patients with sickle are risk of hyphema triggering acute narrow angle closure glaucoma. </div>
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<b>Investigations</b></div>
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Two group and saves if transfusion likely - patients with sickle cell likely to have abnormal antigens. </div>
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D-dimers are unhelpful as levels are usually elevated. </div>
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CXR, ABG, LFTs (jaundice or abdo pain), reticulocytes, blood and urine cultures (if febrile), USS abdo, parvovirus B19 serology (Hb drop, low reticulocytes Transient red cell aplasia (TRCA) is caused by infection with parvovirus B19, which causes red cell production to halt for 3-7 days), brain imaging, limb x-rays, CRP. </div>
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Consider serology for atypical respiratory organisms and urine for pneumococcal and legionella antigen. </div>
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Look for mycoplasma infection - red cell agglutination on a stained blood film and cold agglutinins in serum.</div>
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Look for parvovirus B19 - erythema infectiosum or slapped cheeks, gloves and socks syndrome (painful erythema of hands and feet), arthropathy, aplastic crisis.</div>
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<b>Management</b></div>
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Oxygen - only if sats are low. </div>
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Antibiotics - really consider antibiotics if CRP>25 - but not amoxicillin as it is so similar to pen v - consider co-amox or tax. Stop prophylactic antibiotics if starting regular treatment. Prophylactic penicillin should be used in children until five years old, unless they had a splenectomy or invasive pneumococcal infection. </div>
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Transfusion - consider. If Jehovah's witness need transfusion, go ahead as per normal, then contact legal department who arrange out of court hearing and you can normally transfuse them within an hour! And most parents are happy because they've done their bit. </div>
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Hydroxycarbamide (also known as hydroxyurea) - stop if febrile or low platelets as can cause cardiomyopathy and neutropenia. </div>
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Hydroxyurea - more than three crisis in twelve years, or sickle cell-associated pain, or any infants older than nine months. </div>
Folic acid - 5mg OD<br />
Hydrozine - 25mg BD PO for itching<br />
Analgesia<br />
Hydration - oral if tolerated<br />
Thrombo-prophylaxis<br />
<br />
<b>NICE Guidelines</b><br />
- Treat as a medical emergency<br />
- Analgesia within 30min<br />
- Obs<br />
- Offer opioid bolus for severe and moderate pain<br />
- Do NOT give pethidine<br />
<br />
- Offer patients PCA, and treat opiate side effects<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZAGDeFYK-nOVE9Kx-MoGBfHbqfhfGcnBNqOpCCcfpYh4It3W4pkKocKg2K1M3TJMTBWzyz0UXSPSvKVruYyulljrWTUG_uJXWe7fiTO5Pij1LImPCrEYhB-u5zxcMIb5d5RUIHseKBRE/s1600/Sickle.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZAGDeFYK-nOVE9Kx-MoGBfHbqfhfGcnBNqOpCCcfpYh4It3W4pkKocKg2K1M3TJMTBWzyz0UXSPSvKVruYyulljrWTUG_uJXWe7fiTO5Pij1LImPCrEYhB-u5zxcMIb5d5RUIHseKBRE/s320/Sickle.jpg" width="226" /></a></div>
<br />
<br />
<b>References</b><br />
<a href="http://learning.bmj.com/learning/module-intro/.html?moduleId=10047809&searchTerm=%E2%80%9Csickle%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/.html?moduleId=10047809&searchTerm=%E2%80%9Csickle%E2%80%9D&page=1&locale=en_GB</a><br />
<a href="http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease.jpg">http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease.jpg</a><br />
<a href="http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease%20signs.jpg">http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease%20signs.jpg</a><br />
<a href="http://www.epmonthly.com/departments/cme/cme-archive/sickle-cell-10-things-every-ep-should-know-about-scd-/">http://www.epmonthly.com/departments/cme/cme-archive/sickle-cell-10-things-every-ep-should-know-about-scd-/</a><br />
<a href="http://learning.bmj.com/learning/module-intro/.html?moduleId=10047809&searchTerm=%E2%80%9Csickle%E2%80%9D&page=1&locale=en_GB%20http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease.jpg%20http://calgaryguide.ucalgary.ca/slide.aspx?slide=Sickle%20cell%20disease%20signs.jpg%20http://www.epmonthly.com/departments/cme/cme-archive/sickle-cell-10-things-every-ep-should-know-about-scd-/%20http://www.nice.org.uk/guidance/cg143/chapter/recommendations%20%20http://thorax.bmj.com/content/58/8/726.full%20http://lifeinthefastlane.com/ccc/sickle-cell-crisis/%20http://wikem.org/wiki/Sickle_cell_crisis%20http://wikem.org/wiki/Acute_Chest_Syndrome%20http://radiopaedia.org/articles/sickle-cell-disease%20http://www.nice.org.uk/guidance/cg143/chapter/recommendations%20%20http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines%20http://www.bcshguidelines.com/documents/sicklecelldisease_bjh_2003.pdf%20http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/%20http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/#fever http://emedicine.medscape.com/article/205926-treatment https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_61.pdf http://www.spah.scot.nhs.uk/Documents/Adult%20Guidelines.pdf http://www.transfusionguidelines.org.uk/transfusion-handbook/8-effective-transfusion-in-medical-patients/8-6-haemoglobinopathies http://www.ststn.co.uk/wp-content/uploads/2012/02/e.-hydroxyurea-2010.pdf http://www.nice.org.uk/guidance/cg143" target="_blank">http://www.nice.org.uk/guidance/cg143/chapter/recommendations </a><br />
<a href="http://thorax.bmj.com/content/58/8/726.full">http://thorax.bmj.com/content/58/8/726.full</a><br />
<a href="http://lifeinthefastlane.com/ccc/sickle-cell-crisis/">http://lifeinthefastlane.com/ccc/sickle-cell-crisis/</a><br />
<a href="http://wikem.org/wiki/Sickle_cell_crisis">http://wikem.org/wiki/Sickle_cell_crisis</a><br />
<a href="http://wikem.org/wiki/Acute_Chest_Syndrome">http://wikem.org/wiki/Acute_Chest_Syndrome</a><br />
<a href="http://radiopaedia.org/articles/sickle-cell-disease">http://radiopaedia.org/articles/sickle-cell-disease</a><br />
<a href="http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines">http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines</a><br />
<a href="http://www.bcshguidelines.com/documents/sicklecelldisease_bjh_2003.pdf">http://www.bcshguidelines.com/documents/sicklecelldisease_bjh_2003.pdf</a><br />
<a href="http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/">http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/</a><br />
<a href="http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/#fever">http://www.rch.org.au/clinicalguide/guideline_index/Sickle_Cell_Disease_Guideline/#fever</a><br />
<a href="http://emedicine.medscape.com/article/205926-treatment">http://emedicine.medscape.com/article/205926-treatment</a><br />
<a href="https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_61.pdf">https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_61.pdf</a><br />
<a href="http://www.spah.scot.nhs.uk/Documents/Adult%20Guidelines.pdf">http://www.spah.scot.nhs.uk/Documents/Adult%20Guidelines.pdf</a><br />
<a href="http://www.transfusionguidelines.org.uk/transfusion-handbook/8-effective-transfusion-in-medical-patients/8-6-haemoglobinopathies">http://www.transfusionguidelines.org.uk/transfusion-handbook/8-effective-transfusion-in-medical-patients/8-6-haemoglobinopathies</a><br />
<a href="http://www.ststn.co.uk/wp-content/uploads/2012/02/e.-hydroxyurea-2010.pdf">http://www.ststn.co.uk/wp-content/uploads/2012/02/e.-hydroxyurea-2010.pdf</a><br />
<br />
<a href="http://www.nice.org.uk/guidance/cg143">http://www.nice.org.uk/guidance/cg143</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com6tag:blogger.com,1999:blog-3554867121225781336.post-58435289554166854852015-06-07T03:22:00.001-07:002019-07-20T14:04:41.348-07:00Dehydration - Pyloric Stenosis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi97t3AE_05uoT-rmFpyWuz_4BfKvXdNoJMhsVpY-RlsveTBDskGKr0e3ZmcVgKIjzM1d8CBRV2hxtXBVuVueRCFWg_jKcFxV-FQToIzkyQgvl4o0Ry51nB2DkQoYsMWbvVqiJ-3jSC8sw/s1600/Syllabus.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi97t3AE_05uoT-rmFpyWuz_4BfKvXdNoJMhsVpY-RlsveTBDskGKr0e3ZmcVgKIjzM1d8CBRV2hxtXBVuVueRCFWg_jKcFxV-FQToIzkyQgvl4o0Ry51nB2DkQoYsMWbvVqiJ-3jSC8sw/s320/Syllabus.jpg" width="320" /></a></div>
<br />
I've probably missed something, but PAP7 seems very similar to <a href="http://paediatricem.blogspot.co.uk/2013/10/dehydration-in-children.html" target="_blank">dehydration in children</a>. The new bit is pyloric stenosis, also known as hypertrophic pyloric stenosis, which we'll cover here.<br />
<br />
<b>Cause</b><br />
There is hypertrophy and hyperplasia of the two muscular layers of the pylorus. This labels the gastric atrum. The pyloric canal becomes lengthened and the whole pylorus becomes thickened. The stomach may then become markedly dilated.<br />
<br />
<b>Associations</b><br />
First-born white males<br />
Northern European ancestry<br />
Family history (7%)<br />
Bottle feeding<br />
Macrolide antibiotics for infants<br />
<br />
<b>Presentation</b><br />
Pyloric stenosis normally starts in the first 3 weeks of life.<br />
Non-bilious vomiting or regurgitation - projectile in 70% of cases.<br />
The infant is still hungry after feeding and may be jaundiced.<br />
Signs of dehydration and malnutrition.<br />
Firm,non-tender and mobile hard pylorus 1-2cm in the RUQ. Best palpated when vomited and calm. Happens in 60-80%.<br />
<br />
<b>Investigations</b><br />
Bloods: Severe metabolic alkalosis with partial respiratory compensation<br />
Hypokalemia<br />
<br />
Hypochloremia<br />
Hyponatraemic, hypokalaemia --> or maybe higher because of dehydration<br />
Alkaline Urine<br />
AXR: Distended stomach with minimal distal intestinal bowel gas<br />
USS: Pylorus hypertrophy<br />
<br />
<b>Management</b><br />
NG Tube if vomiting<br />
Fluid resuscitation<br />
Correct electrolyte abnormalities<br />
Nil by mouth<br />
Surgeons for a pyloromyotomy - splitting muscle layer of the pylorus<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixiQ1V7vMqAL4X79YB9YjNjLxvFH1seeEWJJ6K7x6oPkPOAsHuuTc2HjjXhRO2eUru9AN8EfPhJNr0us32mXFH-575HsnMLS-IOqP4yYU-QGAdWl-xvM4GVt4r382R9n2KivyInj3-h4o/s1600/PyloricStenosis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixiQ1V7vMqAL4X79YB9YjNjLxvFH1seeEWJJ6K7x6oPkPOAsHuuTc2HjjXhRO2eUru9AN8EfPhJNr0us32mXFH-575HsnMLS-IOqP4yYU-QGAdWl-xvM4GVt4r382R9n2KivyInj3-h4o/s320/PyloricStenosis.jpg" width="226" /></a></div>
<br />
<b><u>References</u></b><br />
<a href="http://us.bestpractice.bmj.com/best-practice/monograph/680.html">http://us.bestpractice.bmj.com/best-practice/monograph/680.html</a><br />
<a href="http://lifeinthefastlane.com/ccc/pyloric-stenosis/">http://lifeinthefastlane.com/ccc/pyloric-stenosis/</a><br />
<a href="http://radiopaedia.org/articles/pyloric-stenosis">http://radiopaedia.org/articles/pyloric-stenosis</a><br />
<a href="http://prehospitalmed.com/2013/02/18/levitans-no-desat-with-nasal-cannula-for-infants-with-pyloric-stenosis-requiring-intubation/">http://prehospitalmed.com/2013/02/18/levitans-no-desat-with-nasal-cannula-for-infants-with-pyloric-stenosis-requiring-intubation/</a><br />
<a href="http://lifeinthefastlane.com/tag/pyloric-stenosis/">http://lifeinthefastlane.com/tag/pyloric-stenosis/</a><br />
<a href="http://pemlit.org/2013/04/13/12th-april-2013-electrolyte-profile-of-paediatric-patients-with-hypertrophic-pyloric-stenosis/">http://pemlit.org/2013/04/13/12th-april-2013-electrolyte-profile-of-paediatric-patients-with-hypertrophic-pyloric-stenosis/</a><br />
<a href="http://emedicine.medscape.com/article/803489-overview">http://emedicine.medscape.com/article/803489-overview</a><br />
<a href="http://www.rcemlearning.co.uk/modules/my-baby-is-throwing-up-and-its-getting-me-down/">http://www.rcemlearning.co.uk/modules/my-baby-is-throwing-up-and-its-getting-me-down/</a>4<br />
<a href="https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap7/">https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap7/</a><br />
<br />
http://broomedocs.com/2013/02/clinical-case-079-is-it-pyloric-stenosis/ may be useful - their server is still down so I haven't read it yet!Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com1tag:blogger.com,1999:blog-3554867121225781336.post-43262619320350809142015-06-05T06:13:00.003-07:002015-06-05T06:13:44.225-07:00Functional Abdominal PainFunctional abdominal pain is mentioned in the higher syllabus for abdominal pain, and not the core syllabus. It is common in children, and some resources suggest it has a non-organic cause in most cases - some don't. Either way, a cause is difficult to elucidate, with a cause identified in <10%. It is important to consider physical and psychological factors. Functional abdominal syndrome is abdominal pain for 25% of the time, with other symptoms.<br />
Apley's law: the further a recurrent abdominal pain is from the umbilicus, the more likely it is to be organic.<br />
<br />
40% of 7 year olds have at least one episode of abdominal pain, with peaks in incidence at 5 and 10 years old.<br />
<br />
Recurrent pain: more common in girls than boys<br />
more common in children whose parents have GI problems<br />
obesity<br />
Winter<br />
<br />
<div style="text-align: center;">
<b><i>3 of more episodes of abdominal pain in three months, that affects daily activities. </i></b></div>
<div style="text-align: center;">
<b>Pain not associated with eating, loss of daily functioning, no other disorder</b></div>
<div style="text-align: center;">
<br /></div>
<div style="text-align: left;">
<b>Causes</b></div>
<div style="text-align: left;">
There is no clear idea what causes recurrent abdominal pain. The biophysical model of disease suggests it's a response to biological factors, family and school interactions, family environment and critical life events. </div>
<div style="text-align: left;">
It is thought, by Rome III, there are three main categories of functional abdominal pain:</div>
<div style="text-align: left;">
Duodenal Ulcers</div>
<div style="text-align: left;">
Abdominal Migraine</div>
<div style="text-align: left;">
Irritable Bowel Syndrome</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<i>Duodenal Ulcers or Functional Dyspepsia: </i></div>
<div style="text-align: left;">
Consider in epigastric pain that causes night time waking. Treat by giving PPIs. Test for and treat H Pylori. If symptoms do not respond, then get an endoscopy - if the endoscopy is normal, consider functional dyspepsia.</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<i>Irritable Bowel Syndrome</i></div>
<div style="text-align: left;">
Intestinal dysmotility. Family history is common, and the infection may follow a GI infection. You normally get abdominal pain that is worse before defecation - and relieved by defacation. It can be helpeful to say to children that sometimes the insides of the intestine become so sensitive that some children can feel the food going round the bends. </div>
<div style="text-align: left;">
Peppermint oil may be helpful. </div>
<div style="text-align: left;">
Avoiding sorbitol can be helpful, and increasing intake of oats and linseed can help. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<i>Abdominal Migraine</i></div>
<div style="text-align: left;">
Abdominal migraine is associated with travel sickness. This may be associated with a headache, but in some children the abdominal pain predominates. The pain is normally midline associated with vomiting and pallor. There is normally a history of migraine. </div>
<div style="text-align: left;">
Pizotifen may be helpful. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<b>Management</b></div>
<div style="text-align: left;">
Make sure you differentiate between serious and dangerous diagnoses. Serious is a disruption to schooling and life. Dangerous is life threatening. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
- Urine culture and microscopy</div>
<div style="text-align: left;">
- FBC, ESR, CRP, LFTs, U&E, Coeliac</div>
<div style="text-align: left;">
- Stool microsccopy </div>
<div style="text-align: left;">
- Abdominal USS to exclude gall stones and PUJ obstruction</div>
<div style="text-align: left;">
- Pain and life event diary</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<b>Red Flags</b></div>
<div style="text-align: left;">
Unexplained fever</div>
<div style="text-align: left;">
Weight loss and poor growth</div>
<div style="text-align: left;">
Joint problems, rashes</div>
<div style="text-align: left;">
Vomiting</div>
<div style="text-align: left;">
Pain causing waking, referred to back or shoulders</div>
<div style="text-align: left;">
Urinary symptoms, perianal disease, PR blood </div>
<div style="text-align: left;">
Age under 5 </div>
<div style="text-align: left;">
<br /></div>
<u>References</u><br />
<a href="http://learning.bmj.com/learning/module-intro/functional-recurrent-abdominal-pain-children-assessment-management.html?moduleId=10017102&searchTerm=%E2%80%9Cabdominal%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/functional-recurrent-abdominal-pain-children-assessment-management.html?moduleId=10017102&searchTerm=%E2%80%9Cabdominal%E2%80%9D&page=1&locale=en_GB</a><br />
<br />
<a href="http://gut.bmj.com/content/45/suppl_2/II43.full">http://gut.bmj.com/content/45/suppl_2/II43.full</a><br />
<div>
<div>
<a href="http://www.bmj.com/content/325/7366/701?sso=">http://www.bmj.com/content/325/7366/701?sso=</a></div>
<div>
<a href="http://gut.bmj.com/content/45/suppl_2/II60.full%C2%A0" target="_blank">http://gut.bmj.com/content/45/suppl_2/II60.full </a></div>
<div>
<a href="http://bestpractice.bmj.com/best-practice/monograph/787/diagnosis/differential-diagnosis.html">http://bestpractice.bmj.com/best-practice/monograph/787/diagnosis/differential-diagnosis.html</a></div>
<div>
<a href="http://www.amazon.co.uk/Illustrated-Textbook-Paediatrics-STUDENTCONSULT-Online/dp/0723435650">http://www.amazon.co.uk/Illustrated-Textbook-Paediatrics-STUDENTCONSULT-Online/dp/0723435650</a></div>
</div>
Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com2tag:blogger.com,1999:blog-3554867121225781336.post-17089027093923296742015-06-03T13:57:00.000-07:002016-11-17T08:02:55.373-08:00Foreign BodiesChildren often swallow things. The management pretty much depends on what they have swallowed, and whether they have symptoms or not. If the child is coughing, consider that they may have inhaled the foreign body instead - the inhaled FB can act as a ball-valve and air can enter but not leave.<br />
<br />
<b><u>The Object</u></b><br />
Button batteries, objects >5mm and sharp, and razor blades are considered dangerous. Button batteries are toxic, and have a slow but deep action, and can also cause direct pressure necrosis. Their effects may be seen after they have been removed. Open safety pins might be dangerous - sharp objects have a 15 - 35% risk of perforation.<br />
<br />
<b><u>Imaging</u></b><br />
<b>1. X-ray </b>if likely to be radio-opaque or "dangerous". Request a neck and chest x-ray- an abdomen is not needed, and irradiates the gonads un-necessarily.<br />
Look at the x-ray carefully- common points that get stuck are:<br />
- C6 is cricopharyngeal sling and upper oesophageal sphincter<br />
- 15% get stuck in the midoesophagus where the aortic arch and carina push on the oesophagus.<br />
- 15% get stuck in the lower oesophageal sphincter / oesophagogastric junction<br />
Check carefully it is a coin and not a button battery. If you are not sure if the coin is in the oesophagus or not, do a lateral film. If the coin is in the oesophagus, it appears coronal. Tracheal objects appear in a sagittal orientation.<br />
<br />
<b>2. Dangerous Object </b>- refer to surgeons where ever the object is. There is some debate about button batteries if they are below the diaphragm. Above the diaphragm - in the oesophagus, nose or throat, they need to come out ASAP.<br />
<br />
<b>3. Above diaphragm, symptomatic, - </b>refer to the surgeons. Most (75%) objects impact in the upper oesophagus.<br />
<b>b. Mild or no symptoms - </b>home, repeat x-ray 24 hours.<br />
<br />
<b>4. Below diaphragm</b><br />
Reassure, return if symptoms develop<br />
<br />
<b>5. Asymptomatic, not seen </b><b style="font-style: italic;">- </b>reassure and return if symptoms develop.<br />
<b>b. Symptomatic - </b>refer to surgeons<br />
<br />
There is no need to search the poo. It might take six weeks for the foreign body to come out.<br />
<br />
<b><u>Metal Detector</u></b><br />
The metal detector can help prove whether a FB is above the diaphragm or not. They can confirm whether the coin has reached the stomach.<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54W0Z2nPg0soU9JTuQdbOsuy08_dyouia6p1sJohsUBxYNXv4q7fTnuIu8RN40eQ447eiJ4DANpmNroBAfzW5dTRXgRICLnIpUZ4TEiGUu77rkTPP6Dcf3hZZcQVaP-DrdWRLyh0q_t4/s1600/ForeignObjects.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="141" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54W0Z2nPg0soU9JTuQdbOsuy08_dyouia6p1sJohsUBxYNXv4q7fTnuIu8RN40eQ447eiJ4DANpmNroBAfzW5dTRXgRICLnIpUZ4TEiGUu77rkTPP6Dcf3hZZcQVaP-DrdWRLyh0q_t4/s200/ForeignObjects.jpg" width="200" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
(flowchart from the amazing and well worth buying <a href="http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X">http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X</a></div>
<br />
<br />
<div>
<span style="color: #373737; font-family: "helvetica neue" , "helvetica" , "arial" , sans-serif;"><span style="font-size: 15px; line-height: 24.375px;"><u>References</u></span></span></div>
<div>
<a href="http://dontforgetthebubbles.com/the-magic-coin/">http://dontforgetthebubbles.com/the-magic-coin/</a><br />
<a href="http://dontforgetthebubbles.com/podcast-week-button-batteries/">http://dontforgetthebubbles.com/podcast-week-button-batteries/</a><br />
<a href="http://lifeinthefastlane.com/ccc/inhaled-foreign-body/">http://lifeinthefastlane.com/ccc/inhaled-foreign-body/</a><br />
<a href="http://lifeinthefastlane.com/top-ten-foreign-bodies/">http://lifeinthefastlane.com/top-ten-foreign-bodies/</a><br />
<a href="http://wikem.org/wiki/Esophageal_foreign_body">http://wikem.org/wiki/Esophageal_foreign_body</a><br />
<a href="http://www.annemergmed.com/article/S0196-0644(84)80573-9/abstract">http://www.annemergmed.com/article/S0196-0644(84)80573-9/abstract</a><br />
<a href="http://lifeinthefastlane.com/paediatric-quiz-017/">http://lifeinthefastlane.com/paediatric-quiz-017/</a><br />
<a href="http://emedicine.medscape.com/article/801821-treatment">http://emedicine.medscape.com/article/801821-treatment</a><br />
<a href="http://www.ncbi.nlm.nih.gov/pubmed/15913481">http://www.ncbi.nlm.nih.gov/pubmed/15913481</a><br />
<a href="http://learnpediatrics.com/body-systems/gastrointestinal/suspected-foreign-body-ingestion/">http://learnpediatrics.com/body-systems/gastrointestinal/suspected-foreign-body-ingestion/</a><br />
<a href="http://www.sciencedirect.com/science/article/pii/S0165587612006519">http://www.sciencedirect.com/science/article/pii/S0165587612006519</a><br />
<a href="http://blog.clinicalmonster.com/2015/03/foreign-body-ingestions-in-children-by-abi-iyanone/">http://blog.clinicalmonster.com/2015/03/foreign-body-ingestions-in-children-by-abi-iyanone/</a><br />
<a href="http://pediatriceducation.org/2005/03/28/">http://pediatriceducation.org/2005/03/28/</a><br />
<a href="http://www.sinaiem.org/pearls/2015/05/26/fool-me-once/">http://www.sinaiem.org/pearls/2015/05/26/fool-me-once/</a><br />
<a href="http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X">http://www.amazon.co.uk/Emergency-Care-Minor-Trauma-Children/dp/144412014X</a><br />
<a href="http://www.amazon.co.uk/books/dp/0199589569">http://www.amazon.co.uk/books/dp/0199589569</a></div>
Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com50tag:blogger.com,1999:blog-3554867121225781336.post-66182917287079271972015-06-02T16:51:00.001-07:002015-06-02T16:51:42.297-07:00ConstipationConstipation is common. DFTB has written some excellent pieces of work on this - I've written myself more of a summary using their resources, and some I've found from elsewhere. <div>
<br /></div>
<div>
<b>Definitions</b></div>
<div>
<div>
RomeIII Criteria: </div>
<div>
≤2 stools per week for a duration of 2 months if patient >2 years</div>
<div>
for duration of 4 months if patient <2 years</div>
<div>
or with evidence of overflow incontinence (no stool, then diarrhoea, then no stool, etc), </div>
<div>
or stools that clog toilet</div>
</div>
<div>
<br /></div>
<div>
Chronic: >8 weeks</div>
<div>
Happens in 5 - 30%of the child population, progressing to chronic in > 1/3 of patients</div>
<div>
<br /></div>
<div>
<3 months, 2-3 stools/ day, 8.5 hours mouth to rectum time</div>
<div>
<2 years, <2/ day, 16 hours mouth to rectum time</div>
<div>
<br /></div>
<div>
<b>Reservoir Constipation</b></div>
<div>
- Too busy to poo, scared to poo leads to reservoir constipation. Stools get larger and harder. Pass a large diameter stool every 1-2 weeks. It's painful to pass these.</div>
<div>
The rectum stretches. The internal sphincter struggles leading to a numb, toneless rectum. Chronically, can lead to anal fissures, which are painful so poo-ing is avoided. The stool continues to become harder and more painful to pass.</div>
<div>
<br /></div>
<div>
<b>Hirschprung's Disease</b></div>
<div>
1/500 live births</div>
<div>
Normally diagnosed in newborns. </div>
<div>
Get abdominal distension that is relieved by rectal stimulation, or enemas.</div>
<div>
<br /></div>
<div>
<b>Cow's Milk: </b>Tolerance may lead to constipation - should be investigated by a specialist before avoiding cow's milk. </div>
<div>
<br /></div>
<div>
<b>Examination</b></div>
<div>
<div>
Weigh the child</div>
<div>
Abdo exam</div>
<div>
Perianal exam – appearance, position, patency, fissures</div>
<div>
Scoliosis + Gait </div>
<div>
Skin overlying the spine – discoloured/sinus/hairy patch/central pit</div>
<div>
Gluteal muscles – is there asymmetry?</div>
<div>
Neuro</div>
</div>
<div>
No PR</div>
<div>
<br /></div>
<div>
<b>Red Flag Features</b></div>
<div>
<div>
Constipation from early infancy</div>
<div>
Delay in meconium >48hrs</div>
<div>
Ribbon stools</div>
<div>
Abdo distension & vomiting</div>
<div>
Abnormal appearance of anus including multiple anal fissures</div>
<div>
Asymmetry/flattening of gluteals</div>
<div>
Sacral agenesis, skin changes over spine</div>
<div>
Skin changes overlying spine</div>
<div>
Deformity of lower limbs – talipes</div>
<div>
Abnormal neuromuscular signs</div>
<div>
<br /></div>
<div>
<div>
<b>Treatment</b></div>
<div>
This is summarised so clearly on CYP that I haven't re-written it</div>
</div>
<div>
- Get rid of old, dark, hard and smelly poo</div>
<div>
- Continue treatment for 3 months. </div>
<div>
- Make going to the toilet fun</div>
<div>
<br /></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEM4kK5vuXWd8H3S9-igvcklrgaqdDfWelIHXMqOmE5Hf4vlS1BQm3wgX4yNUzxc2bEB5HnvghRhMjhHSiIUYnT_xNTAMmqW3GWep9JC_zKQtLwSG4YYIE-MQtuQJdyDHZllSlmpd4yoM/s1600/Constipation.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEM4kK5vuXWd8H3S9-igvcklrgaqdDfWelIHXMqOmE5Hf4vlS1BQm3wgX4yNUzxc2bEB5HnvghRhMjhHSiIUYnT_xNTAMmqW3GWep9JC_zKQtLwSG4YYIE-MQtuQJdyDHZllSlmpd4yoM/s320/Constipation.jpg" width="226" /></a></div>
<div>
<br /></div>
<div>
<br /></div>
</div>
<div>
<div>
<br /></div>
<div>
<b>References</b></div>
<div>
<a href="http://dontforgetthebubbles.com/reservoir-constipation/">http://dontforgetthebubbles.com/reservoir-constipation/</a></div>
<div>
<a href="http://www.movicol.com.au/file/Movicol%20DL%20Patient%20Leaflet%2010pp.pdf">http://www.movicol.com.au/file/Movicol%20DL%20Patient%20Leaflet%2010pp.pdf</a></div>
<div>
<a href="http://dontforgetthebubbles.com/constipation-basics/">http://dontforgetthebubbles.com/constipation-basics/</a></div>
<div>
<a href="http://www.nice.org.uk/guidance/cg99/documents/cg99-constipation-in-children-and-young-people-surveillance-review-decision2">http://www.nice.org.uk/guidance/cg99/documents/cg99-constipation-in-children-and-young-people-surveillance-review-decision2</a></div>
<div>
<a href="http://dontforgetthebubbles.com/treatment/">http://dontforgetthebubbles.com/treatment/</a></div>
<div>
<a href="http://dontforgetthebubbles.com/evidence-on-tough-topics/">http://dontforgetthebubbles.com/evidence-on-tough-topics/</a></div>
<div>
<a href="http://learning.bmj.com/learning/module-intro/idiopathic-constipation-nocturnal-enuresis-childhood-management.html?moduleId=10017757&searchTerm=%E2%80%9Cconstipation%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/idiopathic-constipation-nocturnal-enuresis-childhood-management.html?moduleId=10017757&searchTerm=%E2%80%9Cconstipation%E2%80%9D&page=1&locale=en_GB</a></div>
<div>
<a href="http://www.nice.org.uk/guidance/CG99">http://www.nice.org.uk/guidance/CG99</a></div>
<div>
<a href="https://www.networks.nhs.uk/nhs-networks/paediatric-integrated-care-group/documents/CYP%20Constipation%20Pathway%2019.9.2013.docx/file_popview">https://www.networks.nhs.uk/nhs-networks/paediatric-integrated-care-group/documents/CYP%20Constipation%20Pathway%2019.9.2013.docx/file_popview</a></div>
<div>
<a href="http://dontforgetthebubbles.com/constipation-week/">http://dontforgetthebubbles.com/constipation-week/</a></div>
<div>
<a href="http://emergencymedicinecases.com/episode-19-part-2-pediatric-gastroenteritis-acute-constipation-bowel-obstruction/">http://emergencymedicinecases.com/episode-19-part-2-pediatric-gastroenteritis-acute-constipation-bowel-obstruction/</a></div>
<div>
<a href="http://dontforgetthebubbles.com/advice-info-parents/">http://dontforgetthebubbles.com/advice-info-parents/</a></div>
</div>
<div>
<br /></div>
Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com2tag:blogger.com,1999:blog-3554867121225781336.post-75939223441127230392015-05-13T13:17:00.000-07:002015-06-01T11:37:08.846-07:00Ovarian TorsionStrangulated Hernias could rarely include an ovary - 4.9 cases/ 100,000<br />
Ovarian torsion occurs in young women (63% in 7-10yr old), and post-menopausal women<br />
20% of cases occur during pregnancy<br />
<br />
- Bowel takes a long time, so if there's a hard lump, think of a trapped ovary<br />
- It might feel mobile like a bean<br />
- Don't squish the ovary<br />
- More commonly on the right hand side<br />
- More likely if there's a cyst<br />
- 60% of patients also have vomiting<br />
- 3% have peritoneal signs<br />
- 30% have no tenderness to palpation<br />
<br />
<i>Treatment</i><br />
Ovaries can be difficult to reduce but don't become ischaemic as quickly as testicles.<br />
<br />
<u>References</u><br />
<a href="http://pedemmorsels.com/ovarian-torsion/?utm_source=feedburner&utm_medium=twitter&utm_campaign=Feed%3A+FOAMEM+%28FOAM+RSS%29">http://pedemmorsels.com/ovarian-torsion/?utm_source=feedburner&utm_medium=twitter&utm_campaign=Feed%3A+FOAMEM+%28FOAM+RSS%29</a><br />
<a href="http://www.rcemlearning.co.uk/modules/tummy-painagain/">http://www.rcemlearning.co.uk/modules/tummy-painagain/</a><br />
<a href="http://radiopaedia.org/articles/ovarian-torsion">http://radiopaedia.org/articles/ovarian-torsion</a><br />
<a href="http://emlyceum.com/2012/06/21/ovarian-torsion-answers/">http://emlyceum.com/2012/06/21/ovarian-torsion-answers/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com0tag:blogger.com,1999:blog-3554867121225781336.post-11151907173935688382015-05-08T13:37:00.001-07:002015-06-01T11:36:43.821-07:00Paediatric Hernias<div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij-teZrO_KrB35cmj1YJBVcjixSk8p3gupXiAiYFdM4krgRRweKDzDJPjEFQOBbC2hV60BSEmH3geKJG5SUHPCi3dTg-IFMAzoqhkbOiNkObaooocUC_UEZBLbgAJkPywCVjqFIL_mXNo/s1600/Picture.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="125" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij-teZrO_KrB35cmj1YJBVcjixSk8p3gupXiAiYFdM4krgRRweKDzDJPjEFQOBbC2hV60BSEmH3geKJG5SUHPCi3dTg-IFMAzoqhkbOiNkObaooocUC_UEZBLbgAJkPywCVjqFIL_mXNo/s320/Picture.png" width="320" /></a></div>
<i>Epidemiology</i></div>
<div>
Often present within 1st year of life.</div>
<div>
<br /></div>
<div>
<i>Pathophysiology</i></div>
<div>
Indirect - most hernias are indirect and extend through the internal and external rings. Often on the right hand side. </div>
<div>
<br /></div>
<div>
<i>Signs & Symptoms</i></div>
<div>
- Asymptomatic bulge in the groin or scrotum - above the testicle</div>
<div>
- May resolve when calm and supine</div>
<div>
- Analgesia needed before reduction</div>
<div>
<div>
- Gentle traction on the scrotum to help align the hernia sac with the external ring.</div>
<div>
- While keeping gentle traction, squeeze distal to proximal </div>
<div>
- Apply pressure laterally with the index and thumb along each side of the hernia neck and inguinal canal.</div>
<div>
- Imagine you are trying to stretch open the rings.</div>
<div>
- Gently add more pressure distally and help reduce the hernia.</div>
<div>
- This can take up to 40minutes</div>
<blockquote class="twitter-tweet" lang="en">
<div dir="ltr" lang="en">
<a href="https://twitter.com/hashtag/foamed?src=hash">#foamed</a> hernia reduction <a href="http://t.co/hahmWbEaA6">pic.twitter.com/hahmWbEaA6</a></div>
— MEHMET TATLI (@DRMEHMETTATLI) <a href="https://twitter.com/DRMEHMETTATLI/status/582256063304564739">March 29, 2015</a></blockquote>
<script async="" charset="utf-8" src="//platform.twitter.com/widgets.js"></script>
</div>
<div>
<br /></div>
<div>
<i>Incarceration or Strangulation</i></div>
<div>
- Happens in 7 - 30% </div>
<div>
- Severe pain, bilious emesis, blood in stool, signs of peritonitis, redness and oedema on affected side of scrotum</div>
<div>
- Don't attempt to manually reduce<br />
<br />
<b>References</b></div>
<div>
<a href="http://www.bmj.com/content/312/7030/564.full.print?">http://www.bmj.com/content/312/7030/564.full.print?</a></div>
<div>
<a href="http://pedemmorsels.com/inguinal-hernia/">http://pedemmorsels.com/inguinal-hernia/</a></div>
Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com3tag:blogger.com,1999:blog-3554867121225781336.post-28011749034396400102015-05-08T08:32:00.001-07:002015-06-01T11:37:27.279-07:00Penile ProblemsPenile problems in children<br />
<br />
<br />
<b>Hypospadius</b><br />
Correct before 2 years of age. Do NOT circumcise as may need reconstructive surgery<br />
<br />
<b>Phimosis</b><br />
- At 1 year old 50% boys have non-retractile foreskin, by 4yrs 10% and by 16yrs only 1%<br />
- Non-retractile foreskin = balooning on micturition<br />
- Topical corticosteroids can help.<br />
- Encourage patients to maintain good hygiene and gently stretch the foreskin.<br />
<br />
Emergency if causes acute urinary retention<br />
<br />
<b>Paraphimosis</b><br />
Foreskin gets stuck in the retracted position.<br />
Look for a hair tourniquet.<br />
May be secondary to masturbation<br />
Needs analgesia to reduce<br />
<br />
<b>Balanoposthitis</b><br />
<i>Balanitis = </i>cellulitis of the glans<br />
<i>Posthesis = </i>cellulitis of the foreskin<br />
<br />
Can be irritant, bacterial or fungal.<br />
<br />
<i>Management</i><br />
Needs warm baths<br />
Rule out diabetes<br />
Clotrimazole or antibiotic ointment<br />
Normally get oral amox or trimeth too<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4NeWpdnncEplm7nHbTQqTaN3PlYA4JopwG_ZBIk5GhN5NRZg8Enx6H9Vvmc3kpkldoUl_9Vk8zM7OKcnMiRPqtnAEuu2gqzuP0OYu0JacoUpjYEjHW7tJPLr3EdSkBeM41T3LITW85Wo/s1600/Testicles_Penis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi4NeWpdnncEplm7nHbTQqTaN3PlYA4JopwG_ZBIk5GhN5NRZg8Enx6H9Vvmc3kpkldoUl_9Vk8zM7OKcnMiRPqtnAEuu2gqzuP0OYu0JacoUpjYEjHW7tJPLr3EdSkBeM41T3LITW85Wo/s320/Testicles_Penis.jpg" width="226" /></a></div>
<br />
<br />
<b>References</b><br />
<a href="http://emupdates.com/2009/04/01/900-balanitis-vs-balanoposthitis-causes-of-balanoposthitis-rx-conditions-prevented-by-circumcision/">http://emupdates.com/2009/04/01/900-balanitis-vs-balanoposthitis-causes-of-balanoposthitis-rx-conditions-prevented-by-circumcision/</a><br />
<a href="http://www.wikem.org/wiki/Phimosis">http://www.wikem.org/wiki/Phimosis</a><br />
<a href="http://emupdates.com/2009/04/01/899-management-of-phimosis-paraphimosis-causes-consequences-treatment/%C2%A0" target="_blank">http://emupdates.com/2009/04/01/899-management-of-phimosis-paraphimosis-causes-consequences-treatment/ </a><br />
<a href="http://www.bmj.com/content/346/bmj.f3678?sso=%C2%A0" target="_blank">http://www.bmj.com/content/346/bmj.f3678?sso= </a><br />
<a href="http://www.emrap.tv/index.php?option=com_content&view=article&id=106">http://www.emrap.tv/index.php?option=com_content&view=article&id=106</a><br />
<a href="http://www.wikem.org/wiki/Balanoposthitis">http://www.wikem.org/wiki/Balanoposthitis</a><br />
<a href="http://www.amazon.co.uk/Illustrated-Textbook-Paediatrics-STUDENTCONSULT-Online/dp/0723435650">http://www.amazon.co.uk/Illustrated-Textbook-Paediatrics-STUDENTCONSULT-Online/dp/0723435650</a><br />
<br />Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com3tag:blogger.com,1999:blog-3554867121225781336.post-71382702057942998892015-05-08T07:59:00.000-07:002015-05-08T07:59:30.885-07:00Non Torsion Scrotum<b>Idiopathic Scrotal Oedema</b><br />
<div>
<i>Pathophysiology</i></div>
<div>
"Cellulitis of the scrotum"</div>
<div>
- Unknown cause</div>
<div>
- Hypothesized that it represents a hypersensitivity reaction, similar to angioneurotic oedema</div>
<div>
<br /></div>
<div>
<i>Signs</i></div>
<div>
- May have a small scrotal scratch or insect bite </div>
<div>
- Pre-schoolers</div>
<div>
- Starts as a small spot, then extends to cover half of the scrotum.</div>
<div>
- No testicular tenderness - examine through unaffected skin</div>
<div>
<br /></div>
<div>
<i>Management</i></div>
<div>
- Self resolving</div>
<div>
- NSAIDs and antibiotics have been used. </div>
<div>
<br /></div>
<div>
<div>
<b><br /></b></div>
<div>
<b>Epididymo-orchitis</b></div>
<div>
<i>Pathophysiology</i></div>
<div>
- Affects very young or very old.</div>
<div>
<br /></div>
<div>
<i>Management</i></div>
<div>
- Infants - exclude urinary tract abnormalities - renal USS + urine culture</div>
<div>
- Post pubertal - consider sexual contact</div>
<div>
<br /></div>
</div>
<div>
<div>
<b>Hydrocele of the cord</b></div>
<div>
This often presents as a “third ball”. For elective management. </div>
</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYq9tObweHE0TXN3ln6fF9aolFBchXZtuhEumlhCKxNw-qfJoIGx55Qb5IzchTZH3ljsf0vcBQRoO4JdtkzymzjfigJT46BzNdbFx11SvzF1sBgRWde738gBc-BxO7rqLgAq4-FFJmqfY/s1600/hydrocele.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="208" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYq9tObweHE0TXN3ln6fF9aolFBchXZtuhEumlhCKxNw-qfJoIGx55Qb5IzchTZH3ljsf0vcBQRoO4JdtkzymzjfigJT46BzNdbFx11SvzF1sBgRWde738gBc-BxO7rqLgAq4-FFJmqfY/s320/hydrocele.jpg" width="320" /></a></div>
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<br /></div>
<div class="separator" style="clear: both;">
<b><br /></b></div>
<div class="separator" style="clear: both;">
<b>Undescended Testes</b></div>
<div class="separator" style="clear: both;">
4% incidence at birth (higher in premature babies), falling to 1% at age 1. </div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<b>Varicocoele</b></div>
<div class="separator" style="clear: both;">
Thought of as “varicose veins” of the testicular veins.</div>
<div class="separator" style="clear: both;">
More common at puberty</div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<i>Signs</i></div>
<div class="separator" style="clear: both;">
Classically feels like a “bag of worms”.</div>
<div class="separator" style="clear: both;">
More commonly on the left, as testicular vein drains into higher-pressured left renal vein with a 90 degree turn </div>
<div class="separator" style="clear: both;">
Dullness/ heaviness / scrotal discomfort</div>
<div class="separator" style="clear: both;">
Varices more prominent with standing or Valsalva</div>
<div class="separator" style="clear: both;">
Does not trans-illuminate</div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<i>Management</i></div>
<div class="separator" style="clear: both;">
Need to exclude any other causes of obstruction at this level (e.g. renal tumour, renal vein thrombosis) --> especially if happens suddenly </div>
<div class="separator" style="clear: both;">
Treat surgically for symptomatic relief</div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<b>Hydrocele</b></div>
<div class="separator" style="clear: both;">
Happens if there is a patent processus vaginalis. </div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<i>Signs</i></div>
<div class="separator" style="clear: both;">
Often asymptomatic bilateral scrotal swellings</div>
<div class="separator" style="clear: both;">
Sometimes have a blueish discoloration</div>
<div class="separator" style="clear: both;">
Transilluminate</div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<i>Management</i></div>
<div class="separator" style="clear: both;">
Most resolve spontaneously </div>
<div class="separator" style="clear: both;">
Surgery if persist beyond 18 - 24 months</div>
<div class="separator" style="clear: both;">
If acute, check no inflammatory process </div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<b>References</b></div>
<div class="separator" style="clear: both;">
<a href="http://radiopaedia.org/articles/acute-idiopathic-scrotal-oedema-1">http://radiopaedia.org/articles/acute-idiopathic-scrotal-oedema-1</a></div>
<div class="separator" style="clear: both;">
<a href="http://learning.bmj.com/learning/module-intro/children-urogenital-conditions.html?moduleId=10042266&searchTerm=%E2%80%9Cscrotum%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/children-urogenital-conditions.html?moduleId=10042266&searchTerm=%E2%80%9Cscrotum%E2%80%9D&page=1&locale=en_GB</a></div>
<div class="separator" style="clear: both;">
<a href="http://learning.bmj.com/learning/module-intro/children-abdominal-conditions.html?moduleId=10042263&locale=en_GB">http://learning.bmj.com/learning/module-intro/children-abdominal-conditions.html?moduleId=10042263&locale=en_GB</a></div>
<div class="separator" style="clear: both;">
</div>
<div class="separator" style="clear: both;">
<a href="http://wikem.org/wiki/Varicocele">http://wikem.org/wiki/Varicocele</a></div>
<div class="separator" style="clear: both;">
<a href="http://wikem.org/wiki/Hydrocele">http://wikem.org/wiki/Hydrocele</a></div>
<div>
And references on testicular torsion page</div>
<div>
<a href="http://www.amazon.co.uk/Illustrated-Textbook-Paediatrics-STUDENTCONSULT-Online/dp/0723435650" target="_blank">The Sunflower Book</a></div>
Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com1tag:blogger.com,1999:blog-3554867121225781336.post-80428486298240291792015-05-08T06:06:00.001-07:002015-05-08T06:06:16.960-07:00Testicular Torsion<b>Anatomy</b><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4dJD8MBlz_ehESraP4TJ-AM1zdWxdNtHKJf5omFqIffpx09kBpepNx-b5pNw-DHTy3Dk_hzJu1UCX7QqlDqxKbYYa5teJp2mm5GDclVkH5ESky9dGmEgG_NmQWl6sneslwSoPJGDnqZY/s1600/Inguinal_Cord.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="287" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4dJD8MBlz_ehESraP4TJ-AM1zdWxdNtHKJf5omFqIffpx09kBpepNx-b5pNw-DHTy3Dk_hzJu1UCX7QqlDqxKbYYa5teJp2mm5GDclVkH5ESky9dGmEgG_NmQWl6sneslwSoPJGDnqZY/s320/Inguinal_Cord.jpg" width="320" /></a></div>
<b><br /></b>
The spermatic cord starts at the deep inguinal ring, then enters the scrotum at the superficial inguinal ring.<br />
The testicular appendage, of hydatid of Morgagni, is a remnant of the Mullerian duct in 90% of cases. It can become twisted, mimicking symptoms of testicular torsion.<br />
<br />
<b>Pathophysiology</b><br />
The testicle can twist and tighten up around the spermatic cord. The twist can happen outside of the scrotum, normally at the external inguinal ring, or inside of the scrotum. Inside is more common, especially in adolescents and young adults, especially if there is a bell clapper deformity.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHJecrf8Idy3lw_UOVDGoCKIFCdx7q1qVVHsAv11dsZ8BaNoRsGQhHh5hK3aTaz96TjllUzCskZogKdLRnblxoaLEhVRaMqyHOgyJmTXvmwLts-M-6j7pFNROMzKKCgACR-PaCVJZ9QT0/s1600/Torsion_Types.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHJecrf8Idy3lw_UOVDGoCKIFCdx7q1qVVHsAv11dsZ8BaNoRsGQhHh5hK3aTaz96TjllUzCskZogKdLRnblxoaLEhVRaMqyHOgyJmTXvmwLts-M-6j7pFNROMzKKCgACR-PaCVJZ9QT0/s1600/Torsion_Types.png" /></a></div>
<br />
In 5-8% of cases, this twisting is triggered by mild or moderate trauma.<br />
<br />
<b>Epidemiology</b><br />
Occurs soon after birth, or at puberty.<br />
Incidence in males <25 is 1 in 4000<br />
<br />
Although it has no physiological function, it can be medically significant in that it can, occasionally, undergo torsion (i.e. become twisted), causing acute one-sided testicular pain and may require surgical excision to achieve relief. 1/3 of patients present with a palpable "blue dot" discoloration on the scrotum. This is nearly diagnostic of this condition. Although if clinical suspicion is high for testicular torsion, a surgical exploration of the scrotum is warranted.<br />
<br />
<b>Symptoms</b><br />
Sudden onset, severe testicular pain - in 2/3 of the canal<br />
Half of all torsions start in the night time<br />
Pain not relieved by elevation of the scrotum<br />
Swelling of the testis or scrotum, oedema or erythema of scrotal skin<br />
Pain may be referred to abdominal or inguino-scrotal regions<br />
No fever or urethral discharge<br />
<br />
<b>Signs</b><br />
High riding testicle with horizontal lie<br />
Loss of cremesteric reflex - Prohn's sign<br />
Large testicle<br />
Blue dot sign - more indicative of testicular appendage torsion<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhK2C48003Vsvq12SMvnh6cnHQ7eNveg8Yr1AHrhyphenhyphenCbuE2VMvWUxNNke_ptviEPUn_8Q65SI_eI8zKcUott2jUG5UKoEJwnPJUIStXi4RBCH2dXAhyphenhyphenHpGasihFgpr9xcdeVTD-3-gQTDVs/s1600/Appendage_Torsoin.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="226" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhK2C48003Vsvq12SMvnh6cnHQ7eNveg8Yr1AHrhyphenhyphenCbuE2VMvWUxNNke_ptviEPUn_8Q65SI_eI8zKcUott2jUG5UKoEJwnPJUIStXi4RBCH2dXAhyphenhyphenHpGasihFgpr9xcdeVTD-3-gQTDVs/s320/Appendage_Torsoin.JPG" width="320" /></a></div>
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Undescended testes are at higher risk - empty scrotum, painful lump in the groin</div>
<br />
<i>Intermittent Testicular Torsion</i><br />
May get spontaneous de-torsion. Short periods of groin pain + vomiting, then spontaneous relief.<br />
<br />
<br />
<b>TWIST Score</b><br />
<br />
Proposed score for assessing testicular torsion in children<br />
Finding<span class="Apple-tab-span" style="white-space: pre;"> </span> Points<br />
Testicular swelling<span class="Apple-tab-span" style="white-space: pre;"> </span> 2<br />
Hard testicle<span class="Apple-tab-span" style="white-space: pre;"> </span> 2<br />
Absent cremasteric reflex<span class="Apple-tab-span" style="white-space: pre;"> </span> 1<br />
Nausea or vomiting<span class="Apple-tab-span" style="white-space: pre;"> </span> 1<br />
High-riding testicle<span class="Apple-tab-span" style="white-space: pre;"> </span> 1<br />
<br />
<b>Treatment</b><br />
Analgesia<br />
Urgent Exploration<br />
Consider manual detorsion if urologist not available - "open the book" - twist outward and laterally. May need to be done 2-3x for complete pain relief.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgg864BwWVZyyxANa_euVACQPsUO02VMXtJcBIBT3SlXfaSl-btFRpUe3dOuBx1Jc4aZ1_D5t2VrnDA_ZtxPCr1sWrkocBQVk202b6O7ibqgsbJwMTobqEiVorpYCztATVaj2-70XrPKMY/s1600/Torsion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgg864BwWVZyyxANa_euVACQPsUO02VMXtJcBIBT3SlXfaSl-btFRpUe3dOuBx1Jc4aZ1_D5t2VrnDA_ZtxPCr1sWrkocBQVk202b6O7ibqgsbJwMTobqEiVorpYCztATVaj2-70XrPKMY/s400/Torsion.jpg" width="281" /></a></div>
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<b>References</b><br />
<a href="http://wikem.org/wiki/Testicular_torsion">http://wikem.org/wiki/Testicular_torsion</a><br />
<a href="http://radiopaedia.org/articles/testicular-torsion">http://radiopaedia.org/articles/testicular-torsion</a><br />
<a href="http://emj.bmj.com/content/17/5/381.full">http://emj.bmj.com/content/17/5/381.full</a><br />
<a href="http://www.bmj.com/content/341/bmj.c3213?sso=">http://www.bmj.com/content/341/bmj.c3213?sso=</a><br />
<a href="http://www.emrap.org/episode/2011/december/testicular">http://www.emrap.org/episode/2011/december/testicular</a><br />
<a href="http://wikem.org/wiki/Testicular_Torsion">http://wikem.org/wiki/Testicular_Torsion</a><br />
<a href="http://dontforgetthebubbles.com/testicular-trouble/">http://dontforgetthebubbles.com/testicular-trouble/</a><br />
<a href="http://academiclifeinem.com/patwari-academy-videos-testicular-torsion-and-acute-scrotal-pain/">http://academiclifeinem.com/patwari-academy-videos-testicular-torsion-and-acute-scrotal-pain/</a><br />
<a href="http://dontforgetthebubbles.com/saving-balls-101-inguinoscrotal-masses/">http://dontforgetthebubbles.com/saving-balls-101-inguinoscrotal-masses/</a><br />
<a href="http://learning.bmj.com/learning/module-intro/testicular-torsion.html?moduleId=10029430&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/testicular-torsion.html?moduleId=10029430&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB</a><br />
<a href="http://learning.bmj.com/learning/module-intro/scrotal-swellings-diagnosis-management.html?moduleId=5003328&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB">http://learning.bmj.com/learning/module-intro/scrotal-swellings-diagnosis-management.html?moduleId=5003328&searchTerm=%E2%80%9Ctorsion%E2%80%9D&page=1&locale=en_GB</a><br />
<a href="http://www.enlightenme.org/learning-zone/tummy-pain%E2%80%A6again">http://www.enlightenme.org/learning-zone/tummy-pain%E2%80%A6again</a><br />
<br />
<a href="http://dontforgetthebubbles.com/saving-balls-101-acute-scrotum/">http://dontforgetthebubbles.com/saving-balls-101-acute-scrotum/</a>Cheerful Elephanthttp://www.blogger.com/profile/14498668760192879855noreply@blogger.com203